Pacing as a Treatment for Reflex-Mediated (Vasovagal, Situational, or Carotid Sinus Hypersensitivity) Syncope: A Systematic Review for the 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.

PubMed

Varosy, Paul D; Chen, Lin Y; Miller, Amy L; Noseworthy, Peter A; Slotwiner, David J; Thiruganasambandamoorthy, Venkatesh

2017-08-01

To determine, using systematic review of the biomedical literature, whether pacing reduces risk of recurrent syncope and relevant clinical outcomes among adult patients with reflex-mediated syncope. MEDLINE (through PubMed), EMBASE, and the Cochrane Central Register of Controlled Trials (through October 7, 2015) were searched for randomized trials and observational studies examining pacing and syncope, and the bibliographies of known systematic reviews were also examined. Studies were rejected for poor-quality study methods and for the lack of the population, intervention, comparator, or outcome(s) of interest. Of 3,188 citations reviewed, 10 studies met the inclusion criteria for systematic review, including a total of 676 patients. These included 9 randomized trials and 1 observational study. Of the 10 studies, 4 addressed patients with carotid sinus hypersensitivity, and the remaining 6 addressed vasovagal syncope. Among the 6 open-label (unblinded) studies, we found that pacing was associated with a 70% reduction in recurrent syncope (relative risk [RR]: 0.30; 95% confidence interval [CI]: 0.15-0.60). When the 2 analyzable studies with double-blinded methodology were considered separately, there was no clear benefit (RR: 0.73; 95% CI: 0.25-2.1), but confidence intervals were wide. The strongest evidence was from the randomized, double-blinded ISSUE-3 (Third International Study on Syncope of Uncertain Etiology) trial, which demonstrated a benefit of pacing among patients with recurrent syncope and asystole documented by implantable loop recorder. There are limited data with substantive evidence of outcome ascertainment bias, and only 2 studies with a double-blinded study design have been conducted. The evidence does not support the use of pacing for reflex-mediated syncope beyond patients with recurrent vasovagal syncope and asystole documented by implantable loop recorder. Copyright © 2017 American College of Cardiology Foundation, American Heart Association, Inc., and Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Pacing as a treatment for reflex-mediated (vasovagal, situational, or carotid sinus hypersensitivity) syncope: A systematic review for the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.

PubMed

Varosy, Paul D; Chen, Lin Y; Miller, Amy L; Noseworthy, Peter A; Slotwiner, David J; Thiruganasambandamoorthy, Venkatesh

2017-08-01

To determine, using systematic review of the biomedical literature, whether pacing reduces risk of recurrent syncope and relevant clinical outcomes among adult patients with reflex-mediated syncope. MEDLINE (through PubMed), EMBASE, and the Cochrane Central Register of Controlled Trials (through October 7, 2015) were searched for randomized trials and observational studies examining pacing and syncope, and the bibliographies of known systematic reviews were also examined. Studies were rejected for poor-quality study methods and for the lack of the population, intervention, comparator, or outcome(s) of interest. Of 3,188 citations reviewed, 10 studies met the inclusion criteria for systematic review, including a total of 676 patients. These included 9 randomized trials and 1 observational study. Of the 10 studies, 4 addressed patients with carotid sinus hypersensitivity, and the remaining 6 addressed vasovagal syncope. Among the 6 open-label (unblinded) studies, we found that pacing was associated with a 70% reduction in recurrent syncope (relative risk [RR]: 0.30; 95% confidence interval [CI]: 0.15-0.60). When the 2 analyzable studies with double-blinded methodology were considered separately, there was no clear benefit (RR: 0.73; 95% CI: 0.25-2.1), but confidence intervals were wide. The strongest evidence was from the randomized, double-blinded ISSUE-3 (Third International Study on Syncope of Uncertain Etiology) trial, which demonstrated a benefit of pacing among patients with recurrent syncope and asystole documented by implantable loop recorder. There are limited data with substantive evidence of outcome ascertainment bias, and only 2 studies with a double-blinded study design have been conducted. The evidence does not support the use of pacing for reflex-mediated syncope beyond patients with recurrent vasovagal syncope and asystole documented by implantable loop recorder. Copyright © 2017 American College of Cardiology Foundation, American Heart Association, Inc., and Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Pacing as a Treatment for Reflex-Mediated (Vasovagal, Situational, or Carotid Sinus Hypersensitivity) Syncope: A Systematic Review for the 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.

PubMed

Varosy, Paul D; Chen, Lin Y; Miller, Amy L; Noseworthy, Peter A; Slotwiner, David J; Thiruganasambandamoorthy, Venkatesh

2017-08-01

To determine, using systematic review of the biomedical literature, whether pacing reduces risk of recurrent syncope and relevant clinical outcomes among adult patients with reflex-mediated syncope. MEDLINE (through PubMed), EMBASE, and the Cochrane Central Register of Controlled Trials (through October 7, 2015) were searched for randomized trials and observational studies examining pacing and syncope, and the bibliographies of known systematic reviews were also examined. Studies were rejected for poor-quality study methods and for the lack of the population, intervention, comparator, or outcome(s) of interest. Of 3188 citations reviewed, 10 studies met the inclusion criteria for systematic review, including a total of 676 patients. These included 9 randomized trials and 1 observational study. Of the 10 studies, 4 addressed patients with carotid sinus hypersensitivity, and the remaining 6 addressed vasovagal syncope. Among the 6 open-label (unblinded) studies, we found that pacing was associated with a 70% reduction in recurrent syncope (relative risk [RR]: 0.30; 95% confidence interval [CI]: 0.15-0.60). When the 2 analyzable studies with double-blinded methodology were considered separately, there was no clear benefit (RR: 0.73; 95% CI: 0.25-2.1), but confidence intervals were wide. The strongest evidence was from the randomized, double-blinded ISSUE-3 (Third International Study on Syncope of Uncertain Etiology) trial, which demonstrated a benefit of pacing among patients with recurrent syncope and asystole documented by implantable loop recorder. There are limited data with substantive evidence of outcome ascertainment bias, and only 2 studies with a double-blinded study design have been conducted. The evidence does not support the use of pacing for reflex-mediated syncope beyond patients with recurrent vasovagal syncope and asystole documented by implantable loop recorder. © 2017 by the American College of Cardiology Foundation, the American Heart Association, Inc., and the Heart Rhythm Society.

Recurrent laughter-induced syncope.

PubMed

Gaitatzis, Athanasios; Petzold, Axel

2012-07-01

Syncope is a common presenting complaint in Neurology clinics or Emergency departments, but its causes are sometimes difficult to diagnose. Apart from vasovagal attacks, other benign, neurally mediated syncopes include "situational" syncopes, which occur after urination, coughing, swallowing, or defecation. A healthy 42-year-old male patient presented to the neurology clinic with a long history of faints triggered by spontaneous laughter, especially after funny jokes. Physical and neurological examination, and electroencephalography and magnetic resonance imaging were unremarkable. There was no evidence to suggest cardiogenic causes, epilepsy, or cataplexy and a diagnosis of laughing syncope was made. Laughter-induced syncope is usually a single event in the majority of cases, but may present as recurrent attacks as in our case. Some cases occur in association with underlying neurological conditions. Prognosis is good in the case of neurally mediated attacks. Laughter may not be recognized by physicians as a cause of syncope, which may lead to unnecessary investigations or misdiagnosis, and affect patients' quality of life.

Efficacy of tilt training in patients with vasovagal syncope.

PubMed

Gajek, Jacek; Zyśko, Dorota; Mazurek, Walentyna

2006-06-01

Besides pharmacological therapy and pacemaker implantation, tilt training is a promising method of treatment in patients with vasovagal syncope (VVS). Tilt training is usually offered to patients with malignant or recurrent VVS which impairs their quality of life and carries a risk of injury. To assess the efficacy of tilt training in patients with VVS. The study group consisted of 40 patients (29 females, 11 males, aged 36.6+/-14 years, range 18-57 years) who underwent tilt training using tilt table testing according to the Westminster protocol. The mean number of syncopal episodes prior to the initiation of tilt training was 6.5+/-4.9 (range 0-20); 3 patients had a history of very frequent faints. According to the VASIS classification, type I VVS (mixed) was diagnosed in 17 patients, type II (cardioinhibitory) in 22 subjects, and type III (vasodepressive) in one patient. Mean follow-up duration was 35.1+/-13.5 months. The control group, which did not undergo the tilt testing programme, consisted of 29 patients with VVS (25 females, 4 males, mean age 44.2+/-15.0 years) who had a mean of 3.3+/-3.2 (range 0-12) syncopal episodes in the past (p <0.05 vs study group); 6 of these patients had only pre-syncopal episodes. Type I VVS was diagnosed in 23 controls and type II VVS in 6 control subjects (syncope occurred during the passive phase of tilt testing in 7 subjects, whereas the remaining 22 fainted during NTG infusion). Of the patients from the study group, 3 underwent pacemaker implantation at the time of the initiation of tilt training. At the end of follow-up, 31 (77.5%) patients remained free from syncope recurrences, 5 had syncopal episodes during the initial phase of tilt training, whereas the remaining 4 continued to suffer from syncopal episodes. Out of 3 patients with presyncope, 2 had no syncope recurrences whereas 1 patient continued to have presyncopal attacks. Out of 3 patients with pacemakers, 1 reported activation of pacing in the interventional mode. During the follow-up period, in 5 patients from the study group the diagnosis of VVS was not confirmed and another condition was diagnosed. In the control group, syncope recurrences occurred in 13 (44.5%) patients (p <0.05 vs study group). In patients with VVS, tilt training is effective in the majority of patients. Syncopal or presyncopal episodes and positive results of tilt testing take place more frequently in the early rather than in the late phase of training. Cessation of tilt training causes a recurrence of positive results of tilt testing in spite of the lack of spontaneous syncopal episodes. During long-term observation, a proper diagnosis, different from VVS, can be established in some patients.

A single-center randomized controlled trial observing the safety and efficacy of modified step-up graded Valsalva manoeuver in patients with vasovagal syncope

PubMed Central

Liu, Xiaoyan; Yu, Yijun; Zeng, Xiaoyun; Li, Huanhuan

2018-01-01

Non-pharmacological therapies, especially the physical maneuvers, are viewed as important and promising strategies for reducing syncope recurrences in vasovagal syncope (VVS) patients. We observed the efficacy of a modified Valsalva maneuver (MVM) in VVS patients. 72 VVS patients with syncope history and positive head-up tilt table testing (HUTT) results were randomly divided into conventional treatment group (NVM group, n = 36) and conventional treatment plus standard MVM for 30 days group (MVM group, n = 36). Incidence of recurrent syncope after 12 months (6.5% vs. 41.2%, P<0.01) and rate of positive HUTT after 30 days (9.7% vs.79.4%, P<0.01) were significantly lower in MVM group than in NVM group. HRV results showed that low frequency (LF), LF/ high frequency (HF), standard deviation of NN intervals (SDNN) and standard deviation of all 5-min average NN intervals (SDANN) values were significantly lower in the NVM and MVM groups than in the control group at baseline. After 30 days treatment, LF, LF/HF, SDNN, SDANN values were significantly higher compared to baseline in MVM group. Results of Cox proportional hazard model showed that higher SDNN and SDANN values at 30 days after intervention were protective factors, while positive HUTT at 30 days after intervention was risk factor for recurrent syncope. Our results indicate that 30 days MVM intervention could effectively reduce the incidence of recurrent syncope up to 12 months in VVS patients, possibly through improving sympathetic function of VVS patients. PMID:29381726

A single-center randomized controlled trial observing the safety and efficacy of modified step-up graded Valsalva manoeuver in patients with vasovagal syncope.

PubMed

He, Li; Wang, Lan; Li, Lun; Liu, Xiaoyan; Yu, Yijun; Zeng, Xiaoyun; Li, Huanhuan; Gu, Ye

2018-01-01

Non-pharmacological therapies, especially the physical maneuvers, are viewed as important and promising strategies for reducing syncope recurrences in vasovagal syncope (VVS) patients. We observed the efficacy of a modified Valsalva maneuver (MVM) in VVS patients. 72 VVS patients with syncope history and positive head-up tilt table testing (HUTT) results were randomly divided into conventional treatment group (NVM group, n = 36) and conventional treatment plus standard MVM for 30 days group (MVM group, n = 36). Incidence of recurrent syncope after 12 months (6.5% vs. 41.2%, P<0.01) and rate of positive HUTT after 30 days (9.7% vs.79.4%, P<0.01) were significantly lower in MVM group than in NVM group. HRV results showed that low frequency (LF), LF/ high frequency (HF), standard deviation of NN intervals (SDNN) and standard deviation of all 5-min average NN intervals (SDANN) values were significantly lower in the NVM and MVM groups than in the control group at baseline. After 30 days treatment, LF, LF/HF, SDNN, SDANN values were significantly higher compared to baseline in MVM group. Results of Cox proportional hazard model showed that higher SDNN and SDANN values at 30 days after intervention were protective factors, while positive HUTT at 30 days after intervention was risk factor for recurrent syncope. Our results indicate that 30 days MVM intervention could effectively reduce the incidence of recurrent syncope up to 12 months in VVS patients, possibly through improving sympathetic function of VVS patients.

[Treatment of recurrent neurocardiogenic syncope with cardiac inhibitors with ipratropium bromide].

PubMed

Friederich, H-C; Michaelsen, J; Hesse, C; Schellberg, D; Schwab, M; Herzog, W

2004-06-01

Pharmacological approaches for the treatment of cardioinhibitory vasovagal syncope are controversially discussed in the literature. In acute treatment of neurocardiogenic syncope, anticholinergics (atropine) are used effectively. Randomised and placebo-controlled clinical trials evaluating the preventive significance of anticholinergic agents in the therapy of cardioinhibitory vasovagal syncope are still missing. We report the case of an 18-year-old male patient with recurrent convulsive, cardioinhibitory neurocardiogenic syncope. Vasovagal syncope occurred predominantly as centrally induced syncope triggered by negative emotions such as fear or by seeing blood. Under resting conditions, the patient revealed increased parasympathetic tone with nocturnal bradycardia of 38 beats/min. In the course of head-up tilt table testing a cardioinhibitory syncope with an asystolic pause of 10 seconds occurred without any prodromes after 10 minutes of upright positioning. In order to inhibit parasympathetic tone, medication with ipratropiumbromide was initiated. Time-variant analysis of heart rate variability (autoregressive model) during head-up tilt table testing showed under the medication with ipratropiumbromide a vagal mediated cardioinhibition to 56 beats/min, but no further sinus arrest. Throughout clinical follow-up of 6 months the patient remained syncope-free under the medication. The usefulness of ipratropiumbromide in inhibiting vagal mediated cardioinhibition will be discussed referring to the case report and to studies evaluating anticholinergic agents in the treatment of neurocardiogenic syncope.

Evaluation of a New Cardiac Pacemaker

ClinicalTrials.gov

2013-06-25

Atrial Fibrillation With 2 or 3° AV or Bifascicular Bundle Branch (BBB) Block; Normal Sinus Rhythm With 2 or 3° AV or BBB Block; Sinus Bradycardia With Infrequent Pauses or Unexplained Syncope With EP Findings

Current and Emerging Uses of Insertable Cardiac Monitors: Evaluation of Syncope and Monitoring for Atrial Fibrillation.

PubMed

Tomson, Todd T; Passman, Rod

Insertable cardiac monitors (ICMs) have provided clinicians with a superb tool for assessing infrequent or potentially asymptomatic arrhythmias. ICMs have shown their usefulness in the evaluation of unexplained syncope, providing high diagnostic yields in a cost-effective manner. While unexplained syncope continues to be the most common reason for their use, ICMs are increasingly being used for the monitoring of atrial fibrillation (AF). Recent trials have demonstrated that a substantial proportion of patients with cryptogenic stroke have AF detected only by the prolonged monitoring provided by ICMs. A particularly promising and emerging use for ICMs is in the management of anticoagulation in patients with known paroxysmal AF. The introduction in recent years of ICMs with automatic AF detection algorithms and continuous remote monitoring in combination with novel oral anticoagulants have opened the door for targeted anticoagulation guided by remote monitoring, a strategy that has recently shown promise in pilot studies of this technique. While further research is needed before official recommendations can be given, this use of ICMs opens exciting new possibilities for personalized medicine that could potentially reduce bleeding risk and improve quality of life in patients with atrial fibrillation.

Recurrent syncope and chronic ear pain

PubMed Central

Clegg, Andrew; Daverede, Luis; Wong, Winson; Loney, Elizabeth; Young, John

2010-01-01

An elderly gentleman presented to hospital with recurrent blackout episodes consistent with syncope and a 3-month history of right ear pain. Significant postural hypotension was recorded. White cell count and C reactive protein were elevated. MRI of the head and neck revealed a soft tissue abnormality in the right nasopharynx and base of skull. Tissue biopsies were obtained and microbiology specimens revealed a mixed growth of pseudomonas and diphtheroids. There was no histological evidence of malignancy. A diagnosis of skull base infection was made. Infective involvement of the carotid sinus was considered to be the cause of the recurrent syncope and postural hypotension. The patient responded well to a 12-week course of intravenous meropenem. Inflammatory markers returned to normal and a repeat MRI after 3 months of treatment showed significant resolution of infection. The syncopal episodes and orthostatic hypotension resolved in parallel with treatment of infection. PMID:22791782

Auricular syncope.

PubMed

Thakar, A; Deepak, K K; Kumar, S Shyam

2008-10-01

To describe a previously unreported syndrome of recurrent syncopal attacks provoked by light stimulation of the external auditory canal. A 13-year-old girl had been receiving treatment for presumed absence seizures, with inadequate treatment response. Imaging was normal. Careful history taking indicated that the recurrent syncopal attacks were precipitated by external auditory canal stimulation. Targeted autonomic function tests confirmed a hyperactive vagal response, with documented significant bradycardia and lightheadedness, provoked by mild stimulation of the posterior wall of the left external auditory canal. Abstinence from ear scratching led to complete alleviation of symptoms without any pharmacological treatment. Reflex syncope consequent to stimulation of the auricular branch of the vagus nerve is proposed as the pathophysiological mechanism for this previously undocumented syndrome.

Diagnostic yield of device interrogation in the evaluation of syncope in an elderly population.

PubMed

D'Angelo, Robert N; Pickett, Christopher C

2017-06-01

Device interrogation has become a standard part of the syncope evaluation for patients admitted with permanent pacemakers (PPM) or implantable cardiac defibrillators (ICD), although few studies have shown interrogation yields clinically useful data. The purpose of this study is to determine the diagnostic yield of device interrogation as well as other commonly performed tests in the workup of unexplained syncope in patients with previously implanted PPMs or ICDs. We retrospectively reviewed records of 88 patients admitted to our medical center for syncope with previously implanted pacemakers between January 1, 2005 and January 1, 2015 using ICD-9 billing data. Pacemaker interrogation demonstrated an arrhythmia as the cause for syncope in 4 patients (4%) and evidence of device failure secondary to perforation in 1 patient (1%). The cause of syncope was unknown in 34 patients (39%). Orthostatic hypotension was the most commonly identified cause of syncope (26%), followed by vasovagal syncope (13%), autonomic dysfunction (5%), ventricular arrhythmia (3%), atrial arrhythmia (2%), congestive heart failure (2%), stroke (2%), and other less common causes (8%). History was the most important determinant of syncope (36%), followed by orthostatic vital signs (14%), device interrogations (4%), head CT (2%), and transthoracic echocardiogram (1%). Device interrogation is rarely useful for elucidating a cause of syncope without concerning physical exam, telemetry, or EKG findings. Interrogation may occasionally yield paroxysmal arrhythmias responsible for syncopal episode, but these rarely alter clinical outcomes. Interrogation appears to be more useful in patients with syncope after recent device placement. Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.

Pacing for neurally mediated syncope: is placebo powerless?

PubMed

Brignole, M; Sutton, R

2007-01-01

After two recent controlled trials failed to prove superiority of cardiac pacing over placebo in patients affected by neurally mediated syncope, a widely accepted opinion is that cardiac pacing therapy is not very effective and that a strong placebo effect exists. To measure the effect of placebo pacing therapy. We compared the recurrence rate of syncope during placebo vs. no treatment in controlled trials of drug or pacing therapy. Syncope recurred in 38% of 252 patients randomized to placebo pooled from five trials vs. 34% of 881 patients randomized to no treatment pooled from eight trials. The corresponding recurrence rate with active cardiac pacing was 15% in 203 patients from six trials. Placebo is not an effective therapy for neurally mediated syncope. Different selection criteria in patients who are candidates for cardiac pacing-for example, presence, absence, or severity of the cardioinhibitory reflex may separate positive from negative trials.

Cardiac Arrhythmias in Experimental Syncope

DTIC Science & Technology

1958-11-01

cardiac toward respiratory alkalosis . Regardless of arriythmias by stress procedures. It follows these two extremes in the assumed change in that previous...frequently induced by respiratory maneuvers without syncope. Intravenous aidministration of atropine appatently prevented recurrence of cardiac...arrhythmia induced by respiratory maneuvers. Significant cardiac arrhythmia was also noted in simple orthostatic syncope. Loss of consciousness presents a

Cardiovascular Assessment of Falls in Older People

PubMed Central

Tan, Maw Pin; Kenny, Rose Anne

2006-01-01

Falls in older people can be caused by underlying cardiovascular disorders, either because of balance instability in persons with background gait and balance disorders, or because of amnesia for loss of consciousness during unwitnessed syncope. Pertinent investigations include a detailed history, 12-lead electrocardiography, lying and standing blood pressure, carotid sinus massage (CSM), head-up tilt, cardiac electrophysiological tests, and ambulatory blood pressure and heart rate monitoring, which includes external and internal cardiac monitoring. The presence of structural heart disease predicts an underlying cardiac cause. Conversely, the absence of either indicates that neurally mediated etiology is likely. CSM and tilt-table testing should be considered in patients with unexplained and recurrent falls. Holter monitoring over 24 hours has a low diagnostic yield. Early use of an implantable loop recorder may be more cost-effective. A dedicated investigation unit increases the likelihood of achieving positive diagnoses and significantly reduces hospital stay and health expenditure. PMID:18047258

Association Between Baseline Blood Pressures, Heart Rates, and Vasovagal Syncope in Children and Adolescents.

PubMed

Adlakha, Himanshu; Gupta, Ruchi; Hassan, Romana; Kern, Jeffrey H

2018-01-28

Vasovagal syncope is the most common cause of syncope in children and adults, accounting for 50-66% of unexplained syncope. There are no studies establishing the relationship between syncope, baseline heart rate, and blood pressure. To identify a possible association between baseline blood pressure and heart rate with syncope. We conducted a questionnaire-based chart review study. A questionnaire was distributed to the guardian of children between eight and 18 years of age who attended the Pediatric Ambulatory Care Clinic at Flushing Hospital Medical Center. Based on the responses in the questionnaire, subjects were classified either as cases (positive for syncope) or controls (negative for syncope). Children and adolescents with neurological, cardiac, or any medical condition that can cause syncopal episodes were excluded from the study. Data collected from the questionnaire included age, gender, ethnicity, medical history, family history of syncope, and the amount of salt used in food. Anthropometric and vital signs for the current visit (height, weight, BMI, blood pressure, and heart rate) and vital signs from two previous visits were collected from electronic medical records. The data was analyzed using t-test and chi-square test with Microsoft Excel software (Microsoft Office Standard, v. 14, Microsoft; 2010); p<0.05 was considered significant. A total of 197 subjects were included in this study. There were 18 cases and 179 controls. Of the cases, (4/18) 22.2% were more likely to have a systolic blood pressure lower than the 10th percentile for their gender, age, and height as compared with controls (7/179) 3.9%, p = 0.003. The subjects with a history of syncope were more likely to add salt to their food (p = 0.004). There were no significant differences between cases and controls for age, gender, ethnicity between cases and controls for systolic blood pressure. No significant difference was observed between the heart rates of cases and controls. Children and adolescents with syncope were more likely to have a systolic blood pressure lower than the 10th percentile, and there was no difference in the baseline heart rate. In addition, children with syncope were more likely to add salt to their food.

Impact of syncope on quality of life: validation of a measure in patients undergoing tilt testing.

PubMed

Nave-Leal, Elisabete; Oliveira, Mário; Pais-Ribeiro, José; Santos, Sofia; Oliveira, Eunice; Alves, Teresa; Cruz Ferreira, Rui

2015-03-01

Recurrent syncope has a significant impact on quality of life. The development of measurement scales to assess this impact that are easy to use in clinical settings is crucial. The objective of the present study is a preliminary validation of the Impact of Syncope on Quality of Life questionnaire for the Portuguese population. The instrument underwent a process of translation, validation, analysis of cultural appropriateness and cognitive debriefing. A population of 39 patients with a history of recurrent syncope (>1 year) who underwent tilt testing, aged 52.1 ± 16.4 years (21-83), 43.5% male, most in active employment (n=18) or retired (n=13), constituted a convenience sample. The resulting Portuguese version is similar to the original, with 12 items in a single aggregate score, and underwent statistical validation, with assessment of reliability, validity and stability over time. With regard to reliability, the internal consistency of the scale is 0.9. Assessment of convergent and discriminant validity showed statistically significant results (p<0.01). Regarding stability over time, a test-retest of this instrument at six months after tilt testing with 22 patients of the sample who had not undergone any clinical intervention found no statistically significant changes in quality of life. The results indicate that this instrument is of value for assessing quality of life in patients with recurrent syncope in Portugal. Copyright © 2014 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

Syncope cluster in a patient with vasovagal history.

PubMed

Zyśko, Dorota; Sokalski, Leszek; Gajek, Jacek; Loboz-Grudzień, Krystyna

2010-10-01

We report a case of a 55 year-old man with a history of vasovagal syncope who experienced six unexpected syncopal events over the course of two hours. Two of these occurred in the supine position during ECG monitoring, which showed a long-lasting sinus pause. Before the last syncopal episode, the ECG recording was started at the moment when the patient had the recurrence of presyncopal symptoms. Recordings showed sinus rhythm slowing for 12 s and then sinus arrest lasting for 29 s. A thorough clinical examination revealed no relevant abnormalities. The patient was treated with a permanent pacemaker implantation.

Syncope as initial symptom for nephrotic syndrome: a case report

PubMed Central

Wu, Xuemei; Wang, Guangliang; Feng, Jiachun

2015-01-01

Although syncope and nephrotic syndrome are frequently encountered independently in pediatric practice, syncope as the initial symptom for nephrotic syndrome is rarely observed in the pediatric age group. In this report, we present the case of 3-year-old boy with nephrotic syndrome who presented with a history of three episodes of syncope before admission. The syncope occurred after excessive fluid loss or inadequate intake of fluids and was relieved spontaneously. History taking revealed that the early morning palpebral edema, and laboratory tests showed decreased plasma protein levels and elevated serum lipid levels. Nephrotic syndrome was diagnosed, but could not be confirmed histopathologically because the patient’s parent refused consent for biopsy. The patient was managed with fluid expansion, correction of acidosis, and improvement of microcirculation to prevent recurrence of syncope, and glucocorticoids were administered to prevent disease progression. PMID:26629237

Driving safety among patients with neurocardiogenic (vasovagal) syncope.

PubMed

Bhatia, A; Dhala, A; Blanck, Z; Deshpande, S; Akhtar, M; Sra, A J

1999-11-01

Neurocardiogenic syncope is one of the most common causes of syncope. However, the important issue of driving related injury due to syncope in this population is not well defined. Risk of injury due to syncope while driving and driving behavior was evaluated in 155 consecutive patients (92 women and 63 men; mean age 49 +/- 19 years) with history of syncope in whom hypotension and syncope or presyncope could be provoked during head-up tilt testing. Patients with syncope and positive head-up tilt table test were treated with pharmacological therapy. All participants were asked to fill out a detailed questionnaire regarding any driving related injuries and their driving behavior before tilt table testing and during follow-up. Prior to head-up tilt testing two patients had syncope while driving, and one of these patients had syncope related injury during driving. The mean duration of syncopal episodes was 50 +/- 14 months (range 12-72 months). Of the 155 patients, 52 (34%) had no warning prior to syncope, while 103 (6%) had warning symptoms such as dizziness prior to their clinical syncope. Following a diagnosis of neurocardiogenic syncope established by head-up tilt testing, six patients stopped driving on their own. During a median follow-up of 22 months recurrent syncope occurred in five (3.2%) patients. No patient had syncope or injury during driving. In conclusion, syncope and injury while driving in patients with neurocardiogenic syncope is rare. The precise mechanism of this is unclear but may be related to posture during driving. Consensus among the medical community will be needed to provide specific guidelines in these patients.

Syncope: causes, clinical evaluation, and current therapy.

PubMed

Benditt, D G; Remole, S; Milstein, S; Bailin, S

1992-01-01

Syncope is a common clinical problem comprising the sudden loss of both consciousness and postural tone, with a subsequent spontaneous and relatively prompt recovery. Often it is difficult to differentiate a true syncopal spell from other conditions, such as seizure disorders, or from some simple accidents. Even more difficult is the identification of the cause of syncopal episodes. Nonetheless, establishing a definitive diagnosis ia an important task given the high risk of recurrent symptoms. Careful use of noninvasive and invasive cardiovascular studies (including electrophysiologic testing and tilt-table testing) along with selected hematologic, biochemical, and neurologic studies provides, in the majority of cases, the most effective strategy for obtaining a specific diagnosis and for directing therapy.

Efficacy and feasibility of isometric arm counter-pressure manoeuvres to abort impending vasovagal syncope during real life.

PubMed

Croci, Francesco; Brignole, Michele; Menozzi, Carlo; Solano, Alberto; Donateo, Paolo; Oddone, Daniele; Puggioni, Enrico; Lolli, Gino

2004-07-01

Isometric arm exercises are able to increase blood pressure during the phase of impending vasovagal syncope. We evaluated their efficacy and feasibility during daily life in a group of 29 consecutive patients affected by vasovagal syncopes. The patients were trained to use arm tensing and/or handgrip in case of occurrence of symptoms of impending syncope. During 14+/-6 months of follow-up, 260 episodes of impending syncope were reported by 19 patients; the manoeuvres were self-administered by these patients in 98% of cases and were able to abort syncope in 99.6% of cases. Overall, 5 episodes of syncope occurred in 5 patients (17%), in 4 cases without and in 1 with activation of the manoeuvres. Syncope recurred in 4 (40%) of 10 patients aged >65 years versus only 1 (5%) of 19 patients aged < or =65 years, p=0.03. The non-responders had more episodes of impending syncope than responders (37+/-32 vs 3+/-4, p=0.001). Among 19 clinical variables, age in years was the only significant predictor of syncopal recurrence. No patients had injury or other adverse morbidity related to the relapses. Isometric arm counter-pressure manoeuvres are able to abort impending vasovagal syncope in most patients aged < or =65 years. Arm counter-pressure manoeuvres are feasible, safe and well accepted by the patients in the daily life.

Craniocervical Junction Meningiomas without Hydrocephalus Presenting Solely with Syncope: Report of 2 Cases.

PubMed

Champagne, Pierre-Olivier; Bojanowski, Michel W

2018-06-01

To our knowledge, there have not been any reported cases of a meningioma of the craniocervical region presenting solely with syncope as its initial symptom. Only 1 case of meningioma presenting with syncope has been published, but it was associated with hydrocephalus. We report 2 cases of syncope caused by a craniocervical junction meningioma, with syncope being the sole presenting symptom and without hydrocephalus. We discuss the possible pathophysiology, as well as the clinical relevance of this type of presentation. We reviewed the charts, operative details, and imagery of 2 cases of meningioma in the region of the craniocervical junction, with syncope as their sole presenting feature. We also reviewed the literature. In 1 case the syncope occurred spontaneously. In the other, it occurred during a Valsalva maneuver. Both meningiomas were surgically removed via a retromastoid approach. There was no recurrence of syncope following surgery. Following a literature review, we found 1 case of posterior fossa meningioma presenting with syncope, but hydrocephalus was also present. Syncope can be the sole manifestation of a meningioma of the craniocervical junction. Such syncopes are a consequence of transient dysfunction of the autonomous pathways in the medulla and/or of the medulla's output. In the absence of other causes of syncope, a meningioma in this region, even in the absence of hydrocephalus, should not be considered as fortuitous, but rather as the actual cause of syncope. Recognizing this possibility offers the potential for proper diagnosis and appropriate treatment of the syncope. Copyright © 2018 Elsevier Inc. All rights reserved.

Fluoxetine vs. placebo for the treatment of recurrent vasovagal syncope with anxiety sensitivity.

PubMed

Flevari, Panayota; Leftheriotis, Dionyssios; Repasos, Evangelos; Katsaras, Dimitrios; Katsimardos, Andreas; Lekakis, John

2017-01-01

The optimal medical therapy of patients with vasovagal syncope (VVS) remains controversial. Fluoxetine is effective against anxiety and panic disorders, while its use has shown promising results for VVS. Anxiety sensitivity is a personality trait observed in a considerable proportion of patients with VVS, associated with predisposition to anxiety and panic disorders. Our aim was to examine whether fluoxetine exerts beneficial effects regarding VVS prevention in the subset of patients with anxiety sensitivity. We assessed 106 patients with typical history of recurrent VVS, without other comorbidities, and a diagnostic, positive head-up tilt test. A psychiatric examination ruled out clinical psychiatric disease. Their psychological, stress-related profile was assessed by the Anxiety Sensitivity Index (ASI) questionnaire, a 16-item questionnaire, assessing fear of anxiety-related sensations, previously studied in VVS. Patients scoring positive for ASI (n = 60, 57% of the population) were randomized in a 2:1 fashion to receive either 10-40 mg fluoxetine daily (n = 40) or placebo (n = 20), and were followed-up for 1 year. A significant difference was observed between patients receiving fluoxetine and those with placebo, regarding the distribution of syncope-free time during the study (P < 0.05). A significant difference was also observed between the two groups regarding presyncopal events and the total number of patients who experienced syncope or presyncope during follow-up. Sensitivity to anxiety is a common personality trait in recurrent VVS. Fluoxetine is superior to placebo against syncope in these patients. This drug may be a first-line pharmacological treatment for this difficult-to-treat group. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

[Syncope and occupational risk survey: the role of continuing education and multidisciplinary approach].

PubMed

Barbic, F; Angaroni, L; Orlandi, M; Costantino, G; Dipaola, E; Borleri, D; Borchini, R; D'Adda, F; Perego, F; Borella, M; Galli, A; Solbiati, M; Casazza, G; Furlan, R; Seghizzi, P

2011-01-01

Syncope is a common disorder characterized most of the times by a positive clinical outcome. However, it may turn to a life threatening event even for working colleagues and third party when occurring during an high risk job. We have recently found that, out of 670 patients admitted to the Emergency Department (ED) for syncope, about 50% were potential workers, being their age between 18 and 65 years. Also, we found that in this group of patients syncope recurrence was as high as 11% at 6 months. It is unknown how physicians address the problem of the occupational risk in patients suffering from syncope and how occupational aspects are taken into account in the clinical judgment before work readmission. One hundred eighty five doctors (149 occupational physicians, OP), participating in a work-shop on syncope, were asked to fulfill a questionnaire about their clinical experience and their attention to the occupational aspects in patients after syncope. Despite long lasting clinical experience, 41% of OP did not scrutinize syncope as a relevant symptom in their daily activity. 65% of the other specialists were used to address the occupational risk aspects in their syncope patients. A multidisciplinary approach involving continuing education on safety at work might reduce work accidents due to syncope relapse and promote a safe and suitable re-employment of patients with syncope. scrutinize syncope as a relevant symptom in their daily activity. 65% of the other specialists were used to address the occupational risk aspects in their syncope patients. A multidisciplinary approach involving continuing education on safety at work might reduce work accidents due to syncope relapse and promote a safe and suitable re-employment of patients with syncope.

A novel psychophysiological treatment for vasovagal syncope.

PubMed

Khurana, R K; Lynch, J J; Craig, F W

1997-08-01

The objective of this study was to evaluate the efficacy of transactional psychophysiological therapy (TPT) in a patient with recurrent vasovagal syncope (VVS) and to quantify the capacity of human dialogue to effect significant and consistent measurable therapeutic cardiovascular (CV) changes. A 31-year-old nurse with recurrent VVS and a reproducibly abnormal tilt-table test was refractory to pharmacological and conventional psychiatric treatments. She was treated with TPT. Her CV responses during psychotherapy were incorporated into the dialogue as an important source of communicative information, and she was taught psychophysiological techniques to correct exaggerated CV responses. These responses, during 16 weekly and 12 subsequent monthly sessions, were analysed using a one-way multiple analysis of variance. As TPT progressed, the magnitude and lability of CV responses as well as frequency of VVS were reduced. She has been relatively asymptomatic for 14 years posttherapy. In conclusion, (1) TPT may be an effective primary/adjunctive treatment for patients with VVS; (2) TPT may reduce syncopal episodes, perhaps by normalizing limbic input to the brainstem baroreflex system.

Transvenous demand Pacemaker Treatment for intermittent complete Heart Block in a Cat.

PubMed

Forterre, S; Nürnberg, J H; Forterre, F; Skrodzki, M; Lange, P E

2001-11-01

A 13-year-old male neutered domestic shorthaired cat had repeated syncopal episodes over a 6 month period, which had variable duration and continued to increase in frequency. Intermittent ventricular asystole, due to complete heart block, and hyperthyroidism were documented. As the syncopal episodes did not respond to a 4-week medical treatment and symptoms became severe, a transvenous ventricular demand pacemaker system (VVIM) was implanted via the external jugular vein. The unipolar lead was tunneled subcutaneously and connected with the generator in a preformed ventral abdominal muscle pocket. During follow up of 18-months there were no recurrences of the syncopal episodes.

A Comparison of Pattern of Pregnancy Loss in Women with Infertility Undergoing IVF and Women with Unexplained Recurrent Miscarriages Who Conceive Spontaneously

PubMed Central

Tamhankar, Vidya A.; Liu, Beiyu; Yan, Junhao; Li, Tin-Chiu

2015-01-01

Objective. Women with infertility and recurrent miscarriages may have an overlapping etiology. The aim of this study was to compare the pregnancy loss in pregnancies after IVF treatment with spontaneous pregnancies in women with recurrent miscarriages and to assess differences related to cause of infertility. Methods. The outcome from 1220 IVF pregnancies (Group I) was compared with 611 spontaneous pregnancies (Group II) in women with recurrent miscarriages. Subgroup analysis was performed in Group I based on cause of infertility: tubal factor (392 pregnancies); male factor (610 pregnancies); and unexplained infertility (218 pregnancies). Results. The clinical pregnancy loss rate in Group I (14.3%) was significantly lower than that of Group II (25.8%, p < 0.001) and this was independent of the cause of infertility. However the timing of pregnancy loss was similar between Groups I and II. The clinical pregnancy loss rate in Group I was similar in different causes of infertility. Conclusions. The clinical pregnancy loss rate following IVF treatment is lower than that of women with unexplained recurrent miscarriages who conceived spontaneously. This difference persists whether the infertility is secondary to tubal factors, male factors, or unexplained cause. PMID:26576157

Orthostatic hypotension as an unusual clinical manifestation of pheochromocytoma: a case report.

PubMed

Bortnik, Miriam; Occhetta, Eraldo; Marino, Paolo

2008-08-01

Pheochromocytoma is a rare endocrine tumor which can have a highly variable presentation related to increased catecholamine secretion. We report the case of a 74-year-old man in whom recurrent episodes of syncope due to orthostatic hypotension were the only clinical manifestations of this challenging entity. Diagnosis of pheochromocytoma was achieved by biochemical test samples and computed tomography scans. Surgical excision of the tumor resulted in clinical improvement with normalization of catecholamine concentrations and no more episodes of orthostatic hypotension during a follow-up of 24 months. Although rare, pheochromocytoma may frequently cause disorders of orthostatic tolerance; because of its meaningful implications, screening for this entity should be considered in case of recurrent syncopal episodes due to new-onset orthostatic hypotension.

Tilt angles and positive response of head-up tilt test in children with orthostatic intolerance.

PubMed

Lin, Jing; Wang, Yuli; Ochs, Todd; Tang, Chaoshu; Du, Junbao; Jin, Hongfang

2015-01-01

This study aimed at examining three tilt angle-based positive responses and the time to positive response in a head-up tilt test for children with orthostatic intolerance, and the psychological fear experienced at the three angles during head-up tilt test. A total of 174 children, including 76 boys and 98 girls, aged from 4 to 18 years old (mean 11.3±2.8 years old), with unexplained syncope, were randomly divided into three groups, to undergo head-up tilt test at the angles of 60°, 70° and 80°, respectively. The diagnostic rates and times were analysed, and Wong-Baker face pain rating scale was used to access the children's psychological fear. There were no significant differences in diagnostic rates of postural orthostatic tachycardia syndrome and vasovagal syncope at different tilt angles during the head-up tilt test (p>0.05). There was a significant difference, however, in the psychological fear at different tilt angles utilising the Kruskal-Wallis test (χ2=36.398, p<0.01). It was mildest at tilt angle 60° utilising the Kolmogorov-Smirnov test (p<0.01). A positive rank correlation was found between the psychological fear and the degree of tilt angle (r(s)=0.445, p<0.01). Positive response appearance time was 15.1±14.0 minutes at 60° for vasovagal syncope children. There was no significant difference in the time to positive response, at different tilt angles during the head-up tilt test for vasovagal syncope or for postural orthostatic tachycardia syndrome. Hence, it is suggested that a tilt angle of 60° and head-up tilt test time of 45 minutes should be suitable for children with vasovagal syncope.

Recurrent postural vasovagal syncope: sympathetic nervous system phenotypes.

PubMed

Vaddadi, Gautam; Guo, Ling; Esler, Murray; Socratous, Florentia; Schlaich, Markus; Chopra, Reena; Eikelis, Nina; Lambert, Gavin; Trauer, Thomas; Lambert, Elisabeth

2011-10-01

The pathophysiology of vasovagal syncope is poorly understood, and the treatment usually ineffective. Our clinical experience is that patients with vasovagal syncope fall into 2 groups, based on their supine systolic blood pressure, which is either normal (>100 mm Hg) or low (70-100 mm Hg). We investigated neural circulatory control in these 2 phenotypes. Sympathetic nervous testing was at 3 levels: electric, measuring sympathetic nerve firing (microneurography); neurochemical, quantifying norepinephrine spillover to plasma; and cellular, with Western blot analysis of sympathetic nerve proteins. Testing was done during head-up tilt (HUT), simulating the gravitational stress of standing, in 18 healthy control subjects and 36 patients with vasovagal syncope, 15 with the low blood pressure phenotype and 21 with normal blood pressure. Microneurography and norepinephrine spillover increased significantly during HUT in healthy subjects. The microneurography response during HUT was normal in normal blood pressure and accentuated in low blood pressure phenotype (P=0.05). Norepinephrine spillover response was paradoxically subnormal during HUT in both patient groups (P=0.001), who thus exhibited disjunction between nerve firing and neurotransmitter release; this lowered norepinephrine availability, impairing the neural circulatory response. Subnormal norepinephrine spillover in low blood pressure phenotype was linked to low tyrosine hydroxylase (43.7% normal, P=0.001), rate-limiting in norepinephrine synthesis, and in normal blood pressure to increased levels of the norepinephrine transporter (135% normal, P=0.019), augmenting transmitter reuptake. Patients with recurrent vasovagal syncope, when phenotyped into 2 clinical groups based on their supine blood pressure, show unique sympathetic nervous system abnormalities. It is predicted that future therapy targeting the specific mechanisms identified in the present report should translate into more effective treatment.

Prevalence and clinical significance of antinuclear antibodies in Iranian women with unexplained recurrent miscarriage

PubMed Central

Molazadeh, Morteza; Karimzadeh, Hadi; Azizi, Mohammad R

2014-01-01

Background: Antinuclear antibodies (ANAs) in women with recurrent miscarriage have been reported. The presence of moderate to high titers of these antibodies represents an autoimmune condition that can endanger the health of the fetus in pregnant women. Objective: In this study, we evaluated the prevalence of ANAs in Iranian women with a history of two or more unexplained abortion. Materials and Methods: 560 women with unexplained recurrent miscarriage and 560 healthy controls accounted for this study over a period of 13 months. ANAs were detected by indirect immunofluorescence technique. Results: ANAs were detected in 74 of 560 (13.21%) patient with recurrent miscarriage, and in only 5 of 560 (0.9%) controls (p<0.001). ANA positivity was generally found with low-positive results (1.40-1.80) in about 38% of positive cases, whereas moderate titres (1.160-1.320) and high titres (>1.640) were seen in about 46% and 16% of cases respectively. Finally evaluating of microscopic ANA patterns revealed that about half of positive cases had antibodies against DNA- histone complex, associated with systemic lupus erythematosus disease. Conclusion: Antinuclear antibodies are not uncommon in women with unexplained recurrent miscarriage, suggesting the possible role of an autoimmune disorder on abortion, at least in a subgroup of patients. PMID:24799884

[Vasovagal syncope and increased baroreceptor activity: evidence for increased sensibility of the baroreflex and its rapid reversal with acute administration of metoprolol].

PubMed

Pucciarelli, G; De Vecchis, R; Ebraio, F; Corigliano, G G

1997-07-01

In 17 patients suffering from recurrent episodes of vasovagal syncope as well as in 21 healthy subjects without clinical episodes of presyncope or syncope, we evaluated the reflex decrease in heart rate evoked by the phenilephrine test. In the syncopal patients, the measurements were taken 4-12 hours after the clinical appearance of syncope. We divided the syncopal patients as follows: 9 patients, undergoing pharmacological treatment, and 8 untreated patients (drug free arm). In the pharmacological arm of the study, an alternate, randomized administration of metoprolol (150 mg twice daily for 2 days) and verapamil (80 mg every 6 hours for 2 days) was provided. Therefore, in the pharmacological arm as well as in drug free patients, we tested again the baroreflex sensitivity, by means of iv phenilephrine bolus, 3 and 7 days after the clinical appearance of the syncopal event. The baroreflex sensitivity values were significantly higher in the syncopal group compared to the control group (21 +/- 5 vs 13 +/- 4.5 ms/mm Hg; p < 0.01). Of the two tested drugs, only the metoprolol produced a fast (day 3) decrease in baroreflex sensitivity. On the basis of measurements taken after 7 days, we noted a pattern of widespread reduction in baroreflex sensitivity values, found in both treated and untreated patients. In conclusion, patients with vasovagal syncope exhibited a more pronounced maximal parasympathetic activation compared to the control group. The high baroreflex sensitivity values were soon (day 3) reduced by metoprolol, but not by verapamil therapy; a spontaneous normalization in baroreflex sensitivity values was found 7 days after the clinical episode, regardless of therapy.

Effects of the menstrual cycle phases on the tilt testing results in vasovagal patients.

PubMed

Zyśko, Dorota; Gajek, Jacek; Terpiłowski, Lukasz; Agrawal, Anil Kumar; Wróblewski, Paweł; Rudnicki, Jerzy

2012-08-01

The aim of the study was to assess the distribution of positive tilt testing (TT) throughout the menstrual cycle and to determine if the phase of menstrual cycle contributes to the duration of the loss of consciousness. TT results of 183 premenopausal women, aged 29.5 ± 9.8 years, were studied. The menstrual cycle was divided into four phases based on the first day of the last menstrual bleeding: perimenstrual (M), preovulatory (F), periovulatory (O) and postovulatory (L). Positive TT results were equally distributed. In patients with TT in O phase, the highest percentage of NTG provocation was needed. Patients in L phase had significantly lower incidence of cardioinhibitory reaction. The longest duration of loss of consciousness was in the M phase. Multiple regression analysis revealed that the duration of loss of consciousness during positive TT was significantly associated with higher number of syncopal events, TT performed in M phase and lower heart rate at TT termination. Cardiodepressive type of neurocardiogenic reaction was more frequent during M and O phase than during L phase. The distribution of positive TT results as well as syncope and presyncope does not differ throughout the menstrual cycle. Diagnostic TT in premenopausal women with unexplained syncope could be performed irrespective of the phase of menstrual cycle. TT has similar sensitivity throughout the menstrual cycle. During the postovulatory phase, cardioinhibitory reaction is less frequent than in M and O phases. The duration of loss of consciousness is longer during the M phase of the menstrual cycle independently of the higher syncope number and lower heart rate at TT termination.

Emergency department management of syncope: need for standardization and improved risk stratification.

PubMed

Thiruganasambandamoorthy, Venkatesh; Taljaard, Monica; Stiell, Ian G; Sivilotti, Marco L A; Murray, Heather; Vaidyanathan, Aparna; Rowe, Brian H; Calder, Lisa A; Lang, Eddy; McRae, Andrew; Sheldon, Robert; Wells, George A

2015-08-01

Variations in emergency department (ED) syncope management have not been well studied. The goals of this study were to assess variations in management, and emergency physicians' risk perception and disposition decision making. We conducted a prospective study of adults with syncope in six EDs in four cities over 32 months. We collected patient characteristics, ED management, disposition, physicians' prediction probabilities at index presentation and followed patients for 30 days for serious outcomes: death, myocardial infarction (MI), arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage, or procedural interventions. We used descriptive statistics, ROC curves, and regression analyses. We enrolled 3662 patients: mean age 54.3 years, and 12.9 % were hospitalized. Follow-up data were available for 3365 patients (91.9 %) and 345 patients (10.3 %) suffered serious outcomes: 120 (3.6 %) after ED disposition including 48 patients outside the hospital. After accounting for differences in patient case mix, the rates of ED investigations and disposition were significantly different (p < 0.0001) across the four study cities; as were the rates of 30-day serious outcomes (p < 0.0001) and serious outcomes after ED disposition (p = 0.0227). There was poor agreement between physician risk perception and both observed event rates and referral patterns (p < 0.0001). Only 76.7 % (95 % CI 68.1-83.6) of patients with serious outcomes were appropriately referred. There are large and unexplained differences in ED syncope management. Moreover, there is poor agreement between physician risk perception, disposition decision making, and serious outcomes after ED disposition. A valid risk-stratification tool might help standardize ED management and improve disposition decision making.

Current and emerging indications for implantable cardiac monitors.

PubMed

Giada, Franco; Bertaglia, Emanuele; Reimers, Bernhard; Noventa, Donatella; Raviele, Antonio

2012-09-01

Implantable cardiac monitors (ICMs) continuously monitor the patient's electrocardiogram and perform real-time analysis of the heart rhythm, for up to 36 months. The current clinical use of ICMs involves the evaluation of transitory symptoms of possible arrhythmic origin, such as unexplained syncope and palpitations. Moreover, ICMs can also be used for the evaluation of difficult cases of epilepsy and unexplained falls, though current indications for their application in these sectors are less clearly defined. Finally, the ability of new-generation ICMs to automatically record arrhythmic episodes suggests that these devices could also be used to study asymptomatic arrhythmias, and thus could be proposed for the long-term evaluation of the total (symptomatic and asymptomatic) arrhythmic burden in patients at risk of arrhythmic events. In particular, ICMs may have an emerging role in the management of patients with atrial fibrillation and in those at risk of ventricular arrhythmias. ©2012, The Authors. Journal compilation ©2012 Wiley Periodicals, Inc.

Unexplained Cases of Allergic Reactions Linked to Red Meat

MedlinePlus

... that starts after being bitten by a lone star tick may cause unexplained cases of recurrent anaphylaxis. ... after eating meat. Previous studies have linked lone star tick bites to this unusual food allergy. The ...

Gestational age of pregnancy loss in women with unexplained recurrent miscarriage.

PubMed

Ticconi, Carlo; Giuliani, Emma; Sorge, Roberto; Patrizi, Lodovico; Piccione, Emilio; Pietropolli, Adalgisa

2016-03-01

The aim of this study was to investigate the gestational age (GA) of pregnancy loss in women with unexplained recurrent miscarriage (RM) and to determine whether the miscarriages occur at similar GA in RM women. This retrospective study was carried out in a university hospital and included 288 women with unexplained RM. The GA at which each miscarriage occurred was carefully determined. Overall, 739 miscarriages were analyzed. RM women had miscarriages at a median GA of 7 weeks (range: 3-20). In RM women, 47.2% (n = 136) experienced miscarriages within a 1-week range of GA and 53.4% (n = 154) had miscarriages in the same period of fetal development (pre-embryonic, embryonic or fetal). Women with unexplained RM tend to have miscarriages at the same GA, which is characteristic for each patient. © 2015 Japan Society of Obstetrics and Gynecology.

Torsade de pointes in a case of pheochromocytoma--an unusual presentation of an uncommon disease.

PubMed

Roshan, John; George, Oommen K; Vineet, S; George, Paul V; Jose, V Jacob

2004-01-01

We report the case of a middle aged lady with dilated cardiomyopathy, presenting with recurrent syncope due to torsade de pointes. Further evaluation revealed that she had a pheochromocytoma which caused the arrhythmia.

Altered autonomic nervous system activity in women with unexplained recurrent pregnancy loss.

PubMed

Kataoka, Kumie; Tomiya, Yumi; Sakamoto, Ai; Kamada, Yasuhiko; Hiramatsu, Yuji; Nakatsuka, Mikiya

2015-06-01

Autonomic nervous system activity was studied to evaluate the physical and mental state of women with unexplained recurrent pregnancy loss (RPL). Heart rate variability (HRV) is a measure of beat-to-beat temporal changes in heart rate and provides indirect insight into autonomic nervous system tone and can be used to assess sympathetic and parasympathetic tone. We studied autonomic nervous system activity by measuring HRV in 100 women with unexplained RPL and 61 healthy female volunteers as controls. The degree of mental distress was assessed using the Kessler 6 (K6) scale. The K6 score in women with unexplained RPL was significantly higher than in control women. HRV evaluated on standard deviation of the normal-to-normal interval (SDNN) and total power was significantly lower in women with unexplained RPL compared with control women. These indices were further lower in women with unexplained RPL ≥4. On spectral analysis, high-frequency (HF) power, an index of parasympathetic nervous system activity, was significantly lower in women with unexplained RPL compared with control women, but there was no significant difference in the ratio of low-frequency (LF) power to HF power (LF/HF), an index of sympathetic nervous system activity, between the groups. The physical and mental state of women with unexplained RPL should be evaluated using HRV to offer mental support. Furthermore, study of HRV may elucidate the risk of cardiovascular diseases and the mechanisms underlying unexplained RPL. © 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.

Increased Anti-HSP60 and Anti-HSP70 Antibodies in Women with Unexplained Recurrent Pregnancy Loss.

PubMed

Matsuda, Miwa; Sasaki, Aiko; Shimizu, Keiko; Kamada, Yasuhiko; Noguchi, Soichi; Hiramatsu, Yuji; Nakatsuka, Mikiya

2017-06-01

　Vascular dysfunction has been reported in women with recurrent pregnancy loss (RPL). We investigated the severity of vascular dysfunction in non-pregnant women with RPL and its correlation with anti-heat shock protein (HSP) antibodies that are known to induce arteriosclerosis. We measured the serum anti-HSP60 antibodies, anti-HSP70 antibodies, and anti-phospholipid antibodies (APA) in 68 women with RPL and 29 healthy controls. Among the women with RPL, 14 had a diagnosis of antiphospholipid syndrome (APS), and in the remaining 54, the causes for RPL were unexplained. Compared to the controls, the brachial-ankle pulse wave velocity (baPWV), carotid augmentation index (cAI), and uterine artery pulsatility index (PI) were all significantly higher in the women with both APS and unexplained RPL. Compared to the controls, the anti-HSP60 antibody levels were significantly higher in the APA-positive group of women with unexplained RPL, and the anti-HSP70 antibody levels were significantly higher in APS and APA-positive group of women with unexplained RPL. However, the anti-HSP60 and anti-HSP70 antibody levels did not correlate with the values of baPWV or cAI. Our results demonstrated anti-HSP60 and anti-HSP70 antibodies are increased in women with unexplained RPL. Further studies are needed to elucidate the roles of anti-HSP antibodies and their pathophysiology in unexplained RPL.

Effects of closed-loop stimulation vs. DDD pacing on haemodynamic variations and occurrence of syncope induced by head-up tilt test in older patients with refractory cardioinhibitory vasovagal syncope: the Tilt test-Induced REsponse in Closed-loop Stimulation multicentre, prospective, single blind, randomized study.

PubMed

Palmisano, Pietro; Dell'Era, Gabriele; Russo, Vincenzo; Zaccaria, Maria; Mangia, Rolando; Bortnik, Miriam; De Vecchi, Federica; Giubertoni, Ailia; Patti, Fabiana; Magnani, Andrea; Nigro, Gerardo; Rago, Anna; Occhetta, Eraldo; Accogli, Michele

2018-05-01

Closed-loop stimulation (CLS) seemed promising in preventing the recurrence of vasovagal syncope (VVS) in patients with a cardioinhibitory response to head-up tilt test (HUTT) compared with conventional pacing. We hypothesized that the better results of this algorithm are due to its quick reaction in high-rate pacing delivered in the early phase of vasovagal reflex, which increase the cardiac output and the blood pressure preventing loss of consciousness. This prospective, randomized, single-blind, multicentre study was designed as an intra-patient comparison and enrolled 30 patients (age 62.2 ± 13.5 years, males 60.0%) with cardioinhibitory VVS, carrying a dual-chamber pacemaker incorporating CLS algorithm. Two HUTTs were performed one week apart: one during DDD-CLS 60-130/min pacing and the other during DDD 60/min pacing; patients were randomly and blindly assigned to two groups: in one the first HUTT was performed in DDD-CLS (n = 15), in the other in DDD (n = 15). Occurrence of syncope and haemodynamic variations induced by HUTT was recorded during the tests. Compared with DDD, DDD-CLS significantly reduced the occurrence of syncope induced by HUTT (30.0% vs. 76.7%; P < 0.001). In the patients who had syncope in both DDD and DDD-CLS mode, DDD-CLS significantly delayed the onset of syncope during HUTT (from 20.8 ± 3.9 to 24.8 ± 0.9 min; P = 0.032). The maximum fall in systolic blood pressure recorded during HUTT was significantly lower in DDD-CLS compared with DDD (43.2 ± 30.3 vs. 65.1 ± 25.8 mmHg; P = 0.004). In patients with cardioinhibitory VVS, CLS reduces the occurrence of syncope induced by HUTT, compared with DDD pacing. When CLS is not able to abort the vasovagal reflex, it seems to delay the onset of syncope.

Glossopharyngeal neuralgia with syncope.

PubMed

Taylor, P H; Gray, K; Bicknell, P G; Rees, J R

1977-10-01

Thirty-two cases of glossopharyngeal neuralgia complicated by syncope, cardiac arrhythmias or convulsions, singly or together, have been reported in the world literature. A further case is described and the clinical features of these thirty-three are reviewed. It is recommended that treatment should be undertaken as a matter of urgency. In the first place, Carbamezapine, with often the addition of Atropine, may prove effective. However, surgical intervention appears to give a better chance of permanent relief. Four alternative methods of surgery are discussed and the cervical or the intracranial approach recommended. Surgery should not be delayed in patients who fail to respond to medical treatment or in whom recurrence of symptoms occurs.

Asystole caused by Hydroxycut Hardcore: A case report and literature review.

PubMed

Zaidan, Julie; Tabet, Rabih; Karam, Boutros; Daneshvar, Farshid; Raza, Mohammed; Bekheit, Soad

2018-05-01

Obesity is a rising epidemic worldwide driving people to search for remedy through nonconventional therapies. Hydroxycut products are popular supplements used as weight loss aids. Many reports revealed serious adverse effects related to their ingestion. We report the case of a 37-year-old healthy male patient who presented following an episode of syncope. On telemetry, he manifested recurrent sinus node arrests, including a symptomatic 24 s sinus pause. The patient admitted to taking Hydroxycut Hardcore for 10 days previously. After discontinuation of the drug, his symptoms completely resolved. This is the first case of Hydroxycut-associated syncope secondary to bradyarrhythmia. © 2017 Wiley Periodicals, Inc.

Paroxysmal atrioventricular block: Electrophysiological mechanism of phase 4 conduction block in the His-Purkinje system: A comparison with phase 3 block.

PubMed

Shenasa, Mohammad; Josephson, Mark E; Wit, Andrew L

2017-11-01

Paroxysmal atrioventricular (A-V) block is relatively rare, and due to its transient nature, it is often under recognized. It is often triggered by atrial, junctional, or ventricular premature beats, and occurs in the presence of a diseased His-Purkinje system (HPS). Here, we present a 45-year-old white male who was admitted for observation due to recurrent syncope and near-syncope, who had paroxysmal A-V block. The likely cellular electrophysiological mechanisms(s) of paroxysmal A-V block and its differential diagnosis and management are discussed. Continuous electrocardiographic monitoring was done while the patient was in the cardiac unit. Multiple episodes of paroxysmal A-V block were documented in this case. All episodes were initiated and terminated with atrial/junctional premature beats. The patient underwent permanent pacemaker implantation and has remained asymptomatic since then. Paroxysmal A-V block is rare and often causes syncope or near-syncope. Permanent pacemaker implantation is indicated according to the current guidelines. Paroxysmal A-V block occurs in the setting of diseased HPS and is bradycardia-dependent. The detailed electrophysiological mechanisms, which involve phase 4 diastolic depolarization, and differential diagnosis are discussed. © 2017 Wiley Periodicals, Inc.

Emotional stress as a cause of syncope and torsade de pointes in patients with long QT syndrome.

PubMed

Vukmirović, Mihailo; Vukmirović, Irena Tomašević; Angelkov, Lazar; Vukmirović, Filip

2015-02-01

Long QT syndrome (LQTS) is a disorder of myocardial repolarization characterized by the prolongation of QT interval and high risk propensity of torsade de pointes (TdP) that can lead to syncope, cardiac arrest and sudden death. Episodes may be provoked by various stimuli depending on the type of the condition. A 25-year-old famele patient was hospitalized due to syncope that occurred immediately after her solo concert, first time in her life. The patient studied solo singing and after intensive preparations the first solo concert was organized. Electrocardiography (ECG) on admission registered frequent ventricular premature beats (VES), followed by polymorphic ventricular tachycardia--TdP that degenerated into ventricular fibrilation (VF). After immediate cardioversion magnesium and beta-blockers were administered. TdP was registered again several times preceded by VES. The corrected QT interval (QTc) was 516 msec. For secondary prevention of sudden cardiac death, a cardioverter defibrillator was implanted, and beta-blockers continued. After a 1-year follow-up there were no recurrent episodes of TdP, and measured QTc was reduced to 484 msec. Patients with syncope following intensive emotional stress should be evaluated for malignant arrhythmias in the context of LQTS.

Low molecular weight heparin use in unexplained recurrent miscarriage

PubMed Central

Yuksel, Halide; Kayatas, Semra; Boza, Aysen Telce; Api, Murat; Ertekin, A. Aktug; Cam, Cetin

2014-01-01

Objective: The aim of the study was to investigate whether the use of low molecular weight heparin (LMWH) improve live birth rates when compared with control group in patients with unexplained recurrent miscarriages (URM). Methods: In this prospective observational study 150 women with a history of two or more previous unexplained first trimester pregnancy loss who received LMWH; either enoxaparin (n=50), tinzaparin (n=50) or nothing (n=50) were followed for the pregnancy outcome measures. Only the patients who have used standardized dosage of LMWH (4000 IU/day enoxaparin or 3500 IU/day tinzaparin ) were included to the study. The primary end point was the live birth rate and secondary end points were the side effects, late pregnancy complications and neonatal outcome in the study cohorts. Results: Live birth was achieved 85% of the LMWH group and 66% of the control group (p=0.007). According to the subgroup analysis; live birth rates did not differ significantly between the enoxaparin and tinzaparin group (84% and 86%, respectively). Maternal and neonatal side effects were not statistically significant among the study participants. Conclusion: Thromboprophylaxis with LMWH resulted in a improved live-birth rate in patient with 2 or more consecutive unexplained recurrent pregnancy loss. Nevertheless these findings need to be confirmed in larger randomized trials. PMID:25674114

Arrhythmia Secondary to Cold Water Submersion during Helicopter Underwater Escape Training.

PubMed

Kaur, Paven P; Drummond, Sarah E; Furyk, Jeremy

2016-02-01

A 32-year-old, fit and healthy, Caucasian male presented with a less than 24-hour history of palpitations with the onset following participation in helicopter underwater escape training (HUET). He reported no chest pain, shortness of breath, syncope, or pre-syncope symptoms. On examination, an irregularly irregular pulse was noted at a rate of 120 beats per minute with a blood pressure of 132/84. There was no evidence of congestive cardiac failure. The electrocardiogram (ECG) demonstrated atrial fibrillation at 97 beats per minute with a normal axis, normal QRS complexes, and a QTc of 399 ms. Bloods were all within normal limits and a chest x-ray showed no abnormality. The patient was loaded with amiodarone and reverted to sinus rhythm with a normal post-reversion ECG. Five years on, following further HUET, the patient presented with an identical presentation. His ECG showed fast atrial fibrillation at a rate of 115 beats per minute. On this occasion, he was sedated and Direct Current cardioverted with reversal to sinus rhythm after one shock. It was felt that the precipitating factor for this patient's atrial fibrillation, in both cases, was HUET. The case discussed describes a previously fit and well subject who developed a sustained arrhythmia secondary to cold water submersion. Evidence suggests water submersion can provoke cardiac arrhythmias via the suggested theory of "autonomic conflict." It has been proposed that a number of unexplained deaths related to water submersion may be secondary to arrhythmogenic syncope.

Lower frequency of the HLA-G UTR-4 haplotype in women with unexplained recurrent miscarriage.

PubMed

Meuleman, T; Drabbels, J; van Lith, J M M; Dekkers, O M; Rozemuller, E; Cretu-Stancu, M; Claas, F H J; Bloemenkamp, K W M; Eikmans, M

2018-04-01

HLA-G expressed by trophoblasts at the fetal-maternal interface and its soluble form have immunomodulatory effects. HLA-G expression depends on the combination of DNA polymorphisms. We hypothesized that combinations of specific single nucleotide polymorphisms (SNPs) in the 3'untranslated region (3'UTR) of HLA-G play a role in unexplained recurrent miscarriage. In a case control design, 100 cases with at least three unexplained consecutive miscarriages prior to the 20th week of gestation were included. Cases were at time of the third miscarriage younger than 36 years, and they conceived all their pregnancies from the same partner. The control group included 89 women with an uneventful pregnancy. The association of HLA-G 3'UTR SNPs and specific HLA-G haplotype with recurrent miscarriage was studied with logistic regression. Odds ratios (OR) and 95% confidence intervals (95% CI) were reported. Individual SNPs were not significantly associated with recurrent miscarriage after correction for multiple comparisons. However, the presence of the UTR-4 haplotype, which included +3003C, was significantly lower in women with recurrent miscarriage (OR 0.4, 95% CI 0.2-0.8, p = 0.015). In conclusion, this is the first study to perform a comprehensive analysis of HLA-G SNPs and HLA-G haplotypes in a well-defined group of women with recurrent miscarriage and women with uneventful pregnancy. The UTR-4 haplotype was less frequently observed in women with recurrent miscarriage, suggesting an immunoregulatory role of this haplotype for continuation of the pregnancy without complications. Thus, association of HLA-G with recurrent miscarriage is not related to single polymorphisms in the 3'UTR, but is rather dependent on haplotypes. Copyright © 2018 Elsevier B.V. All rights reserved.

Maternal serum amyloid A level as a novel marker of primary unexplained recurrent early pregnancy loss.

PubMed

Ibrahim, Moustafa I; Ramy, Ahmed R; Abdelhamid, Ahmed S; Ellaithy, Mohamed I; Omar, Amna; Harara, Rany M; Fathy, Hayam; Abolouz, Ashraf S

2017-03-01

To assess maternal serum amyloid A (SAA) levels among women with primary unexplained recurrent early pregnancy loss (REPL). A prospective study was conducted among women with missed spontaneous abortion in the first trimester at Ain Shams University Maternity Hospital, Cairo, Egypt, between January 21 and December 25, 2014. Women with at least two consecutive primary unexplained REPLs and no previous live births were enrolled. A control group was formed of women with no history of REPL who had at least one previous uneventful pregnancy with no adverse outcomes. Serum samples were collected to measure SAA levels. The main outcome was the association between SAA and primary unexplained REPL. Each group contained 96 participants. Median SAA level was significantly higher among women with REPL (50.0 μg/mL, interquartile range 26.0-69.0) than among women in the control group (11.6 μg/mL, interquartile range 6.2-15.5; P<0.001). The SAA level was an independent indicator of primary unexplained REPL, after adjusting for maternal age and gestational age (odds ratio 1.12, 95% confidence interval 1.06-1.19; P<0.001). Elevated SAA levels found among women with primary unexplained REPL could represent a novel biomarker for this complication of pregnancy. © 2016 International Federation of Gynecology and Obstetrics.

Rationale for the Assessment of Metoprolol in the Prevention of Vasovagal Syncope in Aging Subjects Trial (POST5).

PubMed

Raj, Satish R; Faris, Peter D; Semeniuk, Lisa; Manns, Braden; Krahn, Andrew D; Morillo, Carlos A; Benditt, David G; Sheldon, Robert S

2016-04-01

Vasovagal syncope (VVS) is a common problem associated with a poor quality of life, which improves when syncope frequency is reduced. Effective pharmacological therapies for VVS are lacking. Metoprolol is a β-adrenergic receptor antagonist that is ineffective in younger patients, but may benefit older (≥40 years) VVS patients. Given the limited therapeutic options, a placebo-controlled clinical trial of metoprolol for the prevention of VVS in older patients is needed. The POST5 is a multicenter, international, randomized, placebo-controlled study of metoprolol in the prevention of VVS in patients ≥40 years old. The primary endpoint is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive metoprolol 25 to 100 mg BID or matching placebo, and followed up for 1 year. Secondary end points include syncope frequency, presyncope, quality of life, and cost analysis. Primary analysis will be intention to treat, with a secondary on-treatment analysis. A sample size of 222, split equally between the groups achieves 85% power to detect a hazard rate of 0.3561 when the event rates are 50% and 30% in the placebo and metoprolol arms. Allowing for 10% dropout, we propose to enroll 248 patients. This study will be the first adequately powered trial to determine whether metoprolol is effective in preventing VVS in patients ≥40 years. If effective, metoprolol may become the first line pharmacological therapy for these patients. Copyright © 2016 Elsevier Inc. All rights reserved.

[Geriatric medicine].

PubMed

Lajoso, Sonia; Launay, Cyrille P; Poloni, Barbara; Büla, Christophe; Gold, Gabriel; Lang, Pierre-Olivier

2017-01-11

In 2016, consequences, contributing factors, and prevention of inappropriate drug prescribing were investigated. Two studies lift the veil on unexplained falls and syncope. A meta-analysis questions the need to adapting transfusion's threshold to comorbidities, and another one the performance of screening for swallowing disorders. The Framingham Heart Study reports the declining of the incidence of vascular dementia. The role played by microbleeds in cognitive deterioration was investigated and aducanumab showed encouraging effect in Alzheimer's disease. When vaccination against influenza for health workers in nursing home was challenged by a meta-analysis this recommendation must be followed. Vaccines against shingles are effective and safe, and a study confirms the efficacy of the HZ7su among 70+.

Arrhythmogenic Right Ventricular Cardiomyopathy with Multiple Thrombi and Ventricular Tachycardia of Atypical Left Branch Bundle Block Morphology.

PubMed

Gong, Shenzhen; Wei, Xin; Liu, Guyue; Wu, Feng; Chen, Xiaoping

2018-04-06

A 61-year-old male patient was admitted to our hospital with recurrent palpitations and syncope. Electrocardiography, echocardiography, and contrast-enhanced computed tomography were performed. The patient was diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) complicated by multiple thrombi, and ventricular tachycardia (VT) without typical left bundle branch block (LBBB) morphology. This case suggests that VT is not always the sole contributor to syncope and death in patients with ARVC, and pulmonary embolism should be considered. Furthermore, VT with typical LBBB morphology is not an absolute necessity as a major criterion for the diagnosis of ARVC when the right heart is extremely enlarged.

Cost-effectiveness analysis of preimplantation genetic screening and in vitro fertilization versus expectant management in patients with unexplained recurrent pregnancy loss.

PubMed

Murugappan, Gayathree; Ohno, Mika S; Lathi, Ruth B

2015-05-01

To determine whether in vitro fertilization with preimplantation genetic screening (IVF/PGS) is cost effective compared with expectant management in achieving live birth for patients with unexplained recurrent pregnancy loss (RPL). Decision analytic model comparing costs and clinical outcomes. Academic recurrent pregnancy loss programs. Women with unexplained RPL. IVF/PGS with 24-chromosome screening and expectant management. Cost per live birth. The IVF/PGS strategy had a live-birth rate of 53% and a clinical miscarriage rate of 7%. Expectant management had a live-birth rate of 67% and clinical miscarriage rate of 24%. The IVF/PGS strategy was 100-fold more expensive, costing $45,300 per live birth compared with $418 per live birth with expectant management. In this model, IVF/PGS was not a cost-effective strategy for increasing live birth. Furthermore, the live-birth rate with IVF/PGS needs to be 91% to be cost effective compared with expectant management. Copyright © 2015 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Ongoing pregnancies in patients with unexplained recurrent pregnancy loss: adverse obstetric outcomes.

PubMed

Cozzolino, Mauro; Rizzello, Francesca; Riviello, Chiara; Romanelli, Chiara; Coccia Elisabetta, Maria

2018-05-25

To investigate the incidence of adverse pregnancy outcomes in couples with an unexplained Recurrent Pregnancy Loss (RPL) history, a retrospective cohort study was conducted between 2014 and 2015. The study group (A) included couples with an unexplained RPL, and the control group (B) was composed of couples who attended the Low-Risk Antenatal Unit during the same period. On the other hand, 53 couples were included in the study group (A) and on the other hand, 65 in the control group (B). Women with previous unexplained recurrent pregnancies loss had a significantly increased risk of gestational diabetes with 12 cases (22.6%) in the study group and 3 cases (4.6%) in the control (OR: 6.048; 95% CI: 1.607-22.762; p = 0.007). A slight increase in the risk of preterm delivery and hepatic cholestasis was observed in the study group (6 cases, 11.3%, in study group and 1 case, 1.5% in the controls (OR: 8.170; 95% CI: 0.951-70.158; p = 0.0555). Women with a history of RPL delivered more frequently by caesarean section (OR: 3.252; 95% CI: 1.460-7.241; p = 0.0039). Women with a history of RPL were at an increased risk for adverse pregnancy outcomes, mainly gestational diabetes. Therefore, a closer surveillance during the antenatal period is recommended in this group of patients.

Use of methylphenidate in the treatment of patients suffering from refractory postural tachycardia syndrome.

PubMed

Kanjwal, Khalil; Saeed, Bilal; Karabin, Beverly; Kanjwal, Yousuf; Grubb, Blair P

2012-01-01

Methylphenidate has been shown to be an effective therapy in patients with refractory neurocardiogenic syncope. However, the role of methylphenidate in patients suffering from postural orthostatic tachycardia (POTS) has not been reported. The study was approved by the institutional review board. A retrospective nonrandomized analysis was preformed on 24 patients evaluated at our autonomic center for POTS from 2003 to 2010. The diagnosis of POTS was based on patient history, physical examination, and response to head up tilt table testing. The mean follow-up period was 9 ± 3 months. The patients were included in the current study if they had a diagnosis of POTS with severe symptoms of orthostatic intolerance and were refractory to the commonly used medications. All of these patients were started on methylphenidate and the response to therapy was considered successful if it provided symptomatic relief. Twenty-four patients (age 28 ± 12, 20 women) met inclusion criterion for this study. The response to treatment was assed subjectively in each patient and was collected in a retrospective fashion from patient charts and physician communications. Four patients reported side effects in the form of nausea and 2 ultimately had to discontinue the treatment. Another 4 patients had a follow-up of less than 6 months. Thus, only 18 patients who received methylphenidate completed the follow-up of 6 months. Out of these 18 patients, 14 (77%) patients reported marked improvement in their symptoms. Nine out of 12 patients who had recurrent episodes of syncope reported no syncope at 6 months of follow-up. Fourteen (77%) patients reported marked improvement in their symptoms of fatigue and presyncope. Four patients continue to have symptoms of orthostatic intolerance and 3 continued to have recurrent episodes of syncope. Methylphenidate may be beneficial in patients with otherwise refractory postural tachycardia syndrome.

Postural blood pressure electrocardiographic changes are associated with falls in older people.

PubMed

Saedon, Nor Izzati; Zainal-Abidin, Imran; Chee, Kok Han; Khor, Hui Min; Tan, Kit Mun; Kamaruzzaman, Shahrul K; Chin, Ai-Vyrn; Poi, Philip J H; Tan, Maw Pin

2016-02-01

To determine the magnitude of postural blood pressure change, differences in ECG between fallers and non-fallers were measured. Postural blood pressure change is associated with symptoms of dizziness, presyncope, and syncope. In this cross-sectional study were included participants from The Malaysian Falls Assessment and Intervention Trial: fallers, aged 65 years or older with two or more falls or one injurious fall in 12 months, from a teaching hospital; and non-fallers, aged 65 years and older found through word-of-mouth and advertising. Noninvasive beat-to-beat blood pressure was measured at 10 min supine rest and 3 min standing. The maximal drop in systolic and diastolic pressure was calculated from a 12-lead ECG interpreted by a cardiologist. Basic demographics, medical history, and symptoms of dizziness, presyncope, and syncope were recorded for all patients. We recruited 155 fallers and 112 non-fallers. Fallers had a significantly longer PR interval (179 ± 32 vs. 168 ± 27 ms, p = 0.013) and a longer corrected QT interval (449 ± 41 vs. 443 ± 39 msec, p = 0.008), and larger change in SBP (28 ± 14 vs. 19 ± 9 mmHg, p < 0.001) with posture change. SBP drop of ≥30mmHg associated with recurrent and injurious falls [odds ratio [95 % confidence interval] = 7.61 (3.18-18.21)]. The changes remained significant after adjustment for symptoms of dizziness, presyncope and syncope. Older individuals with recurrent and injurious falls have significantly longer PR and QT intervals and larger SBP reduction with posture change as compared to non-fallers, and these are not explained by the presence of dizziness, presyncope, or syncope. SBP cut-off of ≥30mmHg considered for postural measurements using continuous BP monitors, the significance of this value needs to be evaluated.

Recurrent syncope attributed to left main coronary artery severe stenosis.

PubMed

Li, Min; Zheng, Xinyi; Liu, Hua; Liu, Yujie

2015-01-01

Patients with acute coronary syndrome (ACS) rarely manifest as recurrent syncope due to malignant ventricular arrhythmia. We report a case of a 56-year-old Chinese male with complaints of paroxysmal chest burning sensation and distress for 2 weeks as well as loss of consciousness for 3 days. The electrocardiogram (ECG) revealed paroxysmal multimorphologic ventricular tachycardia during attack and normal heart rhythm during intervals. Coronary angiograph showed 90% stenosis in left main coronary artery and 80% stenosis in anterior descending artery. Two stents sized 4.0∗18 mm and 2.75∗18 mm were placed at left main coronary artery and anterior descending artery, respectively, during percutaneous coronary intervention (PCI). The patient was discharged and never had ventricular arrhythmia again during a 3-month follow-up since the PCI. This indicated that ventricular tachycardia was correlated with persistent severe myocardial ischemia. Coronary vasospasm was highly suspected to be the reason of the sudden attack and acute exacerbation. PCI is recommended in patients with both severe coronary artery stenosis and ventricular arrhythmia. Removing myocardial ischemia may stop or relieve ventricular arrhythmia and prevent cardiac arrest.

Recurrent syncope, orthostatic hypotension and volatile hypertension: think outside the box.

PubMed

Aung, Thein; Fan, Wuqiang; Krishnamurthy, Mahesh

2013-01-01

The baroreceptors in the neck and aortic arch are important regulators of sudden blood pressure changes. They are innervated by CN IX and X and synapse in the brainstem. Baroreceptor failure is an under-recognized cause of recurrent syncope, orthostatic hypotension, and volatile hypertension, which is refractory to and may in fact worsen with conventional treatments. Baroreflex failure can be the result of neck and chest radiation, head and neck surgery, and cerebrovascular accidents involving the brainstem nuclei. The management of baroreflex failure is a challenge since patient education, lifestyle changes, and family support are extremely important in managing blood pressure. Leg exercises and Thrombo-Embolic Deterrent Stockings (TED) stockings are important in treating orthostatic hypotension. Clonidine is the antihypertensive of choice for supine hypertension. Low-dose benzodiazepines are helpful in suppressing sympathetic surges. We have encountered two patients with baroreflex failure after chemotherapy and radiation to the neck or upper chest. Temporal relationship between symptoms onset and the history of head, neck, and upper chest radiation or trauma is important in reaching a diagnosis.

Interferon Regulatory Factor 5 Gene Polymorphisms in Iranian Women with Unexplained Recurrent Pregnancy Loss.

PubMed

Amiri Jahromi, Rakhshan; Nasiri, Mahboobeh; Jahromi, Athar Rasekh

2017-01-01

This study aimed to examine the association of three functional IRF5 rs10954213, rs3757385, and rs41298401 polymorphisms with susceptibility to unexplained recurrent pregnancy loss (RPL) among Iranian women from south of Iran. 176 women with unexplained RPL and 173 healthy postmenopausal controls were enrolled in this case-control study. Genotyping of the polymorphisms rs10954213 and rs3757385 was carried out using touchdown tetra-primer amplification refractory mutation system-polymerase chain reaction (T-ARMS PCR), and polymorphism rs41298401 was typed using PCR-restriction fragment length polymorphism (PCR-RFLP). Genotype frequencies were significantly different between RPL cases and controls regarding AG heterozygote genotype of rs10954213, GT genotype of rs3757385, and GG genotype of rs41298401. In addition, allele variants (G for rs10954213, T for rs3757385, and G for rs41298401) showed protective role against RPL, while GG haplotype of two first variants was shown to be a susceptibility factor for the disease. These data provide the first evidence, to our knowledge, of the protective role of the studied IRF5 gene polymorphisms against unexplained RPL among Iranian women from south of Iran.

The correlation of sperm morphology with unexplained recurrent spontaneous abortion: A systematic review and meta-analysis

PubMed Central

Cao, Xiaodan; Cui, Yun; Zhang, Xiaoxia; Lou, Jiangtao; Zhou, Jun; Wei, Renxiong

2017-01-01

Sperm morphology displays a potential impact on sperm function and may ultimately impact reproductive function. Current studies have investigated the correlation between sperm morphology with unexplained recurrent spontaneous abortion (RSA) but have shown inconsistent results. Hence, we systematically searched MEDLINE, EMBASE, CNKI databases, as well as the Cochrane Library for studies that examined the association between sperm morphology and unexplained RSA. Fifteen studies were identified, including 883 cases and 530 controls. Our meta-analysis results indicated that the percentage of normal sperm morphology from men with RSA partners was significantly lower than those from normal controls(SMD [95% CI]: − 0.60 [−0.81, −0.40]; P<0.00001) and the percentage of sperm morphologic alterations was significantly higher in patients with RSA compared with the control group (SMD [95% CI]: 0.92 [0.42, 1.43]; P=0.0004). The present study suggested that the percentage of normal sperm morphology may indeed decrease in men from RSA group compared with controls. However, there were some limitations in the study such as the differences in stain techniques and classification criteria. Further evidences are needed to better elucidate the relationship between sperm morphology and unexplained RSA. PMID:28903451

Focal Nodulary Hyperplasia of the Liver Due to Congenital Portosystemic Shunt: A Rare Condition Mimicking Hepatocellulary Carcinoma.

PubMed

Yazal Erdem, Arzu; Emir, Suna; Demir, Haci A; Özyörük, Derya; Çetin, İlker; Turan, Aynur; Karakuş, Esra

2017-01-01

Congenital portosystemic shunts are rare vascular malformations that lead to several complications including liver tumors, pulmonary hypertension, and metabolic encephalopathy. We describe a rare case of a 17-year-old girl with an extrahepatic portosystemic shunt presenting recurrent syncope episodes and a liver mass mimicking hepatocellulary carcinoma.

Recurrent pregnancy loss: current perspectives.

PubMed

El Hachem, Hady; Crepaux, Vincent; May-Panloup, Pascale; Descamps, Philippe; Legendre, Guillaume; Bouet, Pierre-Emmanuel

2017-01-01

Recurrent pregnancy loss is an important reproductive health issue, affecting 2%-5% of couples. Common established causes include uterine anomalies, antiphospholipid syndrome, hormonal and metabolic disorders, and cytogenetic abnormalities. Other etiologies have been proposed but are still considered controversial, such as chronic endometritis, inherited thrombophilias, luteal phase deficiency, and high sperm DNA fragmentation levels. Over the years, evidence-based treatments such as surgical correction of uterine anomalies or aspirin and heparin for antiphospholipid syndrome have improved the outcomes for couples with recurrent pregnancy loss. However, almost half of the cases remain unexplained and are empirically treated using progesterone supplementation, anticoagulation, and/or immunomodulatory treatments. Regardless of the cause, the long-term prognosis of couples with recurrent pregnancy loss is good, and most eventually achieve a healthy live birth. However, multiple pregnancy losses can have a significant psychological toll on affected couples, and many efforts are being made to improve treatments and decrease the time needed to achieve a successful pregnancy. This article reviews the established and controversial etiologies, and the recommended therapeutic strategies, with a special focus on unexplained recurrent pregnancy losses and the empiric treatments used nowadays. It also discusses the current role of preimplantation genetic testing in the management of recurrent pregnancy loss.

Recurrent pregnancy loss: current perspectives

PubMed Central

El Hachem, Hady; Crepaux, Vincent; May-Panloup, Pascale; Descamps, Philippe; Legendre, Guillaume; Bouet, Pierre-Emmanuel

2017-01-01

Recurrent pregnancy loss is an important reproductive health issue, affecting 2%–5% of couples. Common established causes include uterine anomalies, antiphospholipid syndrome, hormonal and metabolic disorders, and cytogenetic abnormalities. Other etiologies have been proposed but are still considered controversial, such as chronic endometritis, inherited thrombophilias, luteal phase deficiency, and high sperm DNA fragmentation levels. Over the years, evidence-based treatments such as surgical correction of uterine anomalies or aspirin and heparin for antiphospholipid syndrome have improved the outcomes for couples with recurrent pregnancy loss. However, almost half of the cases remain unexplained and are empirically treated using progesterone supplementation, anticoagulation, and/or immunomodulatory treatments. Regardless of the cause, the long-term prognosis of couples with recurrent pregnancy loss is good, and most eventually achieve a healthy live birth. However, multiple pregnancy losses can have a significant psychological toll on affected couples, and many efforts are being made to improve treatments and decrease the time needed to achieve a successful pregnancy. This article reviews the established and controversial etiologies, and the recommended therapeutic strategies, with a special focus on unexplained recurrent pregnancy losses and the empiric treatments used nowadays. It also discusses the current role of preimplantation genetic testing in the management of recurrent pregnancy loss. PMID:28553146

Diagnosis of carotid sinus hypersensitivity in older adults: carotid sinus massage in the upright position is essential

PubMed Central

Parry, S; Richardson, D; O'Shea, D; Sen, B; Kenny, R

2000-01-01

OBJECTIVE—To assess the diagnostic value of supine and upright carotid sinus massage in elderly patients.
DESIGN—Prospective controlled cohort study.
SETTING—Three inner city accident and emergency departments and a dedicated syncope facility.
PATIENTS—1375 consecutive patients aged > 55 years presenting with unexplained syncope and drop attacks; 25 healthy controls.
INTERVENTIONS—Bilateral supine carotid sinus massage, repeated in the 70° head up tilt position if the initial supine test was not diagnostic of cardioinhibitory and mixed carotid sinus hypersensitivity.
MAIN OUTCOME MEASURES—Diagnosis of cardioinhibitory or mixed carotid sinus hypersensitivity; clinical characteristics of supine v upright positive groups.
RESULTS—226 patients were excluded for contraindications to carotid sinus massage. Of 1149 patients undergoing massage, 223 (19%) had cardioinhibitory or mixed carotid sinus hypersensitivity; 70 (31%) of these had a positive response to massage with head up tilt following negative supine massage (95% confidence interval, 25.3% to 37.5%). None of the healthy controls showed carotid sinus hypersensitivity on erect or supine massage. The initially positive supine test had 74% specificity and 100% sensitivity; these were both 100% for the upright positive test. The clinical characteristics of the supine v upright positive subgroups were similar.
CONCLUSIONS—The diagnosis of carotid sinus hypersensitivity amenable to treatment by pacing may be missed in one third of cases if only supine massage is performed. Massage should be done routinely in the head up tilt position if the initial supine test is negative.


Keywords: carotid sinus; tilt table testing; syncope; elderly patients PMID:10618329

Stress and recurrent miscarriage.

PubMed

Craig, M

2001-09-01

Our current understanding into the role of stress in unexplained recurrent miscarriages comes from two different research strategies. The majority of research has examined the role of psychological support within this patient population. This support has been provided in a number of ways ranging from weekly interviews with a psychiatrist or gynaecologist and or visual re-assurance in the form of ultrasound scans. A comparison of psychological support with an absence of such intervention has found differences in successful pregnancy outcome varying from as great as 84 versus 26%, respectively. It has been assumed that psychological support reduces the miscarriage rate by reducing “stress”within this patient population. In addition it provides indirect support for a role of stress in the aetiology of unexplained recurrent miscarriage. Other studies have attempted to directly assess the effect of personality characteristics on miscarriage rate; these studies have yielded conflicting results.The mechanism by which stress may be causal in the aetiology of unexplained recurrent miscarriage has not been examined in humans. Animal studies, however, have found that psychological distress can alter immune parameters that may be intricately involved with implantation. These parameters include an elevation of the “abortive” cytokine TNF-a and a reduction in the “anti-abortive” cytokine TGF-P2. Cells that are involved in the release of TNF-a at the feto-maternal interface include T cells, macrophages and mast cells.Mechanisms through which stress may act on these cells are explored and an integrated model is postulated.

Prediction of thrombophilia in patients with unexplained recurrent pregnancy loss using a statistical model.

PubMed

Wang, Tongfei; Kang, Xiaomin; He, Liying; Liu, Zhilan; Xu, Haijing; Zhao, Aimin

2017-09-01

To establish a statistical model to predict thrombophilia in patients with unexplained recurrent pregnancy loss (URPL). A retrospective case-control study was conducted at Ren Ji Hospital, Shanghai, China, from March 2014 to October 2016. The levels of D-dimer (DD), fibrinogen degradation products (FDP), activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), fibrinogen (Fg), and platelet aggregation in response to arachidonic acid (AA) and adenosine diphosphate (ADP) were collected. Receiver operating characteristic curve analysis was used to analyze data from 158 UPRL patients (≥3 previous first trimester pregnancy losses with unexplained etiology) and 131 non-RPL patients (no history of recurrent pregnancy loss). A logistic regression model (LRM) was built and the model was externally validated in another group of patients. The LRM included AA, DD, FDP, TT, APTT, and PT. The overall accuracy of the LRM was 80.9%, with sensitivity and specificity of 78.5% and 78.3%, respectively. The diagnostic threshold of the possibility of the LRM was 0.6492, with a sensitivity of 78.5% and a specificity of 78.3%. Subsequently, the LRM was validated with an overall accuracy of 83.6%. The LRM is a valuable model for prediction of thrombophilia in URPL patients. © 2017 International Federation of Gynecology and Obstetrics.

Is ambulatory monitoring for "community-acquired" syncope economically attractive? A cost-effectiveness analysis of a randomized trial of external loop recorders versus Holter monitoring.

PubMed

Rockx, Marie Antoinette; Hoch, Jeffrey S; Klein, George J; Yee, Raymond; Skanes, Allan C; Gula, Lorne J; Krahn, Andrew D

2005-11-01

Out patient ambulatory monitoring is often performed in patients with syncope that present in the primary care setting to include or exclude an arrhythmia. The cost-effectiveness of 2 monitoring strategies was assessed in a prospective randomized trial. One hundred patients referred for ambulatory monitoring with syncope or presyncope were randomized to a 1-month external loop recorder (n = 49) or 48-hour Holter monitor (n = 51). Patients were offered crossover if there was failed activation or no symptom recurrence. The primary end point was symptom-rhythm correlation during monitoring. Direct costs were calculated based on the 2003 Ontario Health Insurance Plan fee schedule, combined with calculation of labor, materials, service, and overhead for diagnostic testing and related equipment. Before enrollment, the cost of all previous health care resource use was USD 472 +/- USD 397 (range USD 21-USD 1965). In the loop recorder group, 63% of patients had symptom recurrence and successful activation, compared with 24% in the Holter group (P < .0001). The cost per Holter was USD 177.64, and per loop recorder, USD 533.56, with a similar cost per diagnosis with the 2 techniques. The incremental cost-effectiveness ratio of the loop recorder was USD 901.74 per extra successful diagnosis. A strategy of Holter followed by offered loop recorder trended toward lower cost than initial loop recorder followed by Holter (USD 481 +/- USD 267 vs USD 551 +/- USD 83, P = .08), but was associated with a lower overall diagnostic yield (49% vs 63%) and a resultant higher cost per diagnosis (USD 982 vs USD 871, P = .08). Bootstrapping suggested that 90% of incremental cost-effectiveness ratios were less than USD 1250. Despite the increased upfront cost of external loop recorders, the marked improvement in diagnostic yield offsets the cost. External loop recorders are an economically attractive alternative. First-line use of external loop recorders in patients with "community-acquired" syncope and presyncope should be considered to optimize diagnostic yield given its value.

A Randomized Trial of Progesterone in Women with Recurrent Miscarriages.

PubMed

Coomarasamy, Arri; Williams, Helen; Truchanowicz, Ewa; Seed, Paul T; Small, Rachel; Quenby, Siobhan; Gupta, Pratima; Dawood, Feroza; Koot, Yvonne E M; Bender Atik, Ruth; Bloemenkamp, Kitty W M; Brady, Rebecca; Briley, Annette L; Cavallaro, Rebecca; Cheong, Ying C; Chu, Justin J; Eapen, Abey; Ewies, Ayman; Hoek, Annemieke; Kaaijk, Eugenie M; Koks, Carolien A M; Li, Tin-Chiu; MacLean, Marjory; Mol, Ben W; Moore, Judith; Ross, Jackie A; Sharpe, Lisa; Stewart, Jane; Vaithilingam, Nirmala; Farquharson, Roy G; Kilby, Mark D; Khalaf, Yacoub; Goddijn, Mariette; Regan, Lesley; Rai, Rajendra

2015-11-26

Progesterone is essential for the maintenance of pregnancy. However, whether progesterone supplementation in the first trimester of pregnancy would increase the rate of live births among women with a history of unexplained recurrent miscarriages is uncertain. We conducted a multicenter, double-blind, placebo-controlled, randomized trial to investigate whether treatment with progesterone would increase the rates of live births and newborn survival among women with unexplained recurrent miscarriage. We randomly assigned women with recurrent miscarriages to receive twice-daily vaginal suppositories containing either 400 mg of micronized progesterone or matched placebo from a time soon after a positive urinary pregnancy test (and no later than 6 weeks of gestation) through 12 weeks of gestation. The primary outcome was live birth after 24 weeks of gestation. A total of 1568 women were assessed for eligibility, and 836 of these women who conceived naturally within 1 year and remained willing to participate in the trial were randomly assigned to receive either progesterone (404 women) or placebo (432 women). The follow-up rate for the primary outcome was 98.8% (826 of 836 women). In an intention-to-treat analysis, the rate of live births was 65.8% (262 of 398 women) in the progesterone group and 63.3% (271 of 428 women) in the placebo group (relative rate, 1.04; 95% confidence interval [CI], 0.94 to 1.15; rate difference, 2.5 percentage points; 95% CI, -4.0 to 9.0). There were no significant between-group differences in the rate of adverse events. Progesterone therapy in the first trimester of pregnancy did not result in a significantly higher rate of live births among women with a history of unexplained recurrent miscarriages. (Funded by the United Kingdom National Institute of Health Research; PROMISE Current Controlled Trials number, ISRCTN92644181.).

The clinical significance of pregnancy in Brugada syndrome.

PubMed

Rodríguez-Mañero, Moisés; Casado-Arroyo, Rubén; Sarkozy, Andrea; Leysen, Eva; Sieira, Juan Antonio; Namdar, Mehdi; Conte, Gulio; Levinstein, Moisés; Chierchia, Gian-Battista; de Asmundis, Carlo; Brugada, Pedro

2014-03-01

Little is known about the risks and outcomes of pregnancy in women with Brugada syndrome. We therefore evaluated pregnancy outcomes and the influence of pregnancy in patients with Brugada syndrome. A retrospective analysis was performed in all pregnant women with Brugada syndrome. We included 104 women with a total of 219 deliveries. There were 15 spontaneous abortions. One infant died suddenly during the night 3 months after birth. Six pregnant women reported they had experienced at least 1 syncope during the pregnancy. Of the 3 women who received an implantable cardioverter-defibrillator before the pregnancy, none received arrhythmia episodes. There were no events during the pregnancy in 4 patients with a previously aborted sudden cardiac death. Of 24 patients with syncope when not pregnant, 18 were asymptomatic and 6 experienced a recurrent syncope during the pregnancy. During the follow-up (mean follow-up 298.9 days; 95% confidence interval, 289.6-308.2), 2 women received appropriate shocks. In this retrospective, single-center study, serious events were not more frequent during pregnancy and the peripartum period in women with Brugada syndrome. The occurrence of syncope during pregnancy was not associated with a worst outcome in the peri- and postpartum periods or during follow-up. The reported rate of miscarriage and sudden infant death will require further studies to confirm or rule out its association with Brugada syndrome. Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

Unexplained somatic symptoms during major depression: prevalence and clinical impact in a national sample of Italian psychiatric outpatients.

PubMed

Perugi, Giulio; Canonico, Pier Luigi; Carbonato, Paolo; Mencacci, Claudio; Muscettola, Giovanni; Pani, Luca; Torta, Riccardo; Vampini, Claudio; Fornaro, Michele; Parazzini, Fabio; Dumitriu, Arina

2011-01-01

The aim of this study was to explore the prevalence and impact of unexplained somatic symptoms during major depression. A total of 560 consecutive outpatients with a major depressive episode according to the DSM-IV (text revision) were evaluated in 30 psychiatric facilities throughout Italy. 'Unexplained' somatic symptoms were evaluated using the 30-item Somatic Symptoms Checklist (SSCL-30). Somatic symptoms were considered explained if they were best accounted for as coming from a concomitant physical illness or side effects. Patients evaluated their own mood symptomatology using the Zung questionnaires for depression and anxiety and the Hypomania Checklist-32. According to the SSCL-30, only 90 subjects (16.1%) had no unexplained somatic symptoms, while 231 (41.3%) had 1-5 unexplained symptoms and 239 (42.7%) had more than 5. Asthenia was the most commonly observed unexplained somatic symptom (53% of patients). Unexplained somatic symptoms were more common in females and among those suffering from major depression and depression not otherwise specified rather than in patients with recurrent major depression and bipolar disorders. No relationship between unexplained somatic symptoms and hypomanic features was observed. The presence of a large number of unexplained somatic symptoms is associated with more severe depression and higher rates of misdiagnosis and inappropriate treatment. Copyright © 2011 S. Karger AG, Basel.

Polymorphisms in the methylene tetrahydrofolate reductase and methionine synthase reductase genes and their correlation with unexplained recurrent spontaneous abortion susceptibility.

PubMed

Zhu, L

2015-07-28

We aimed to explore the correlation between unexplained recurrent spontaneous abortion and polymorphisms in the methylene tetrahydrofolate reductase (MTHFR) and methionine synthase reductase (MTRR) genes. A case control study was conducted in 118 patients with unexplained recurrent spontaneous abortion (abortion group) and 174 healthy women (control group). The genetic material was extracted from the oral mucosal epithelial cells obtained from all subjects. The samples were subjected to fluorescence quantitative PCR to detect the single nucleotide polymorphisms (SNPs) in the MTHFR (C677T and A1298C) and MTRR (A66G) gene loci. The distribution frequency (18/118, 15.3%) of the MTHFR 677TT genotype was significantly higher in the abortion group (χ2 = 11.006, P = 0.004) than in the control group (2/174, 1.1%); on the other hand, the distribution frequency of the MTHFR A1298C genotype did not significantly differ between the abortion and control groups (χ(2) = 0.441, P = 0.507). The distribution frequency of the MTRR A66G genotype was also significantly higher in the abortion group (14/118, 11.9%; χ(2) = 10.503, P = 0.005) than in the control group (8/174, 4.6%). The MTHFR C677T and MTRR A66G polymorphisms are significantly correlated with the occurrence of spontaneous abortion.

Correlation between three-dimensional power Doppler and morphometric measurement of endometrial vascularity at the time of embryo implantation in women with unexplained recurrent miscarriage.

PubMed

Chen, Xiaoyan; Saravelos, Sotirios H; Liu, Yingyu; Huang, Jin; Wang, Chi Chiu; Li, Tin Chiu

2017-06-01

Power Doppler in combination with three-dimensional (3D-PD) ultrasonography has been used as a noninvasive tool to evaluate the vascularity. However, it is unclear whether 3D-PD can accurately reflect endometrial vascularization and replace the invasive endometrial biopsy. This study aims to investigate the correlation between 3D-PD and micro vessel morphometric measurement of endometrial vascularity. Twenty-five women with unexplained recurrent miscarriage were recruited for 3D-PD and endometrial biopsy on precisely day LH + 7. Immunohistochemistry using vWF was employed to identify micro vessels in endometrial biopsy specimens followed by the use of morphometric technique to measure the mean vessel diameter and volume fractions. The vascularization index (VI), flow index (FI) and vascularization flow index (VFI) assessed by 3D-PD were calculated for both the endometrial and sub-endometrial regions. There were no significant correlations between any of the ultrasonographic measurements (endometrial thickness, endometrial volume, endometrial VI/FI/VFI, sub-endometrial volume, sub-endometrial VI/FI/VFI) and morphometric features (number of micro vessel, mean diameter of micro vessel and volume fraction measurement of vessel). This study indicates that endometrial vascularity assessed by 3D-PD could not be used to reflect changes in micro vessels of the endometrium at the time of embryo implantation in women with unexplained recurrent miscarriage.

Sustained medically unexplained physical symptoms in euthymic patients with recurrent depression: predictive value for recurrence and associations with omega 3- and 6 fatty acids and 5-HTTLPR?

PubMed

Lok, Anja; Assies, Johanna; Koeter, Maarten W J; Bockting, Claudi L H; Wouters, Luuk F; Mocking, Roel J T; Schene, Aart H

2012-02-01

Identification of potentially modifiable risk factors for recurrence in recurrent depression could provide opportunities to improve preventive interventions. In this study we aimed to examine the predictive value of medically unexplained physical symptoms (MUPS) on time to recurrence in recurrent depression. Additionally, to elucidate pathophysiological mechanisms that could explain the relations between MUPS and depression, we investigate the association between a sustained high level of MUPS, and (I) omega (ω)-3 and -6 fatty acid (FA)-status and (II) functional polymorphisms in the promoter region of the serotonin transporter gene (5-HTTLPR). Based on three Physical Symptom Checklist (PCS) scores over 12 months, we defined two groups of remitted recurrently depressed patients: 41 patients with a sustained high number of MUPS and 34 patients with a sustained low number or no MUPS. Patients were followed-up for 3.5 years while recurrence of their depression was monitored. In addition, we analyzed patients' erythrocyte's FA-profiles and triallelically genotyped their 5-HTTLPR. A sustained high level of MUPS predicted consecutive depression recurrence over 3.5 years (adjusted relative risk 2.8). FA-status and distribution of 5-HTTLPR variant frequencies did not differ between patients with sustained high compared to low/absent MUPS-levels. Our sample was relatively small. Remitted recurrently depressed patients with sustained MUPS have a considerably increased risk of recurrence. Having sustained MUPS is not associated with either erythrocyte ω-3 or -6 FA-levels or 5-HTTLPR polymorphism. Recognition and reducing MUPS in an early state could prevent a (depressive) relapse. Copyright © 2011 Elsevier B.V. All rights reserved.

The Molecular Autopsy: Should the Evaluation Continue After the Funeral?

PubMed Central

Tester, David J.; Ackerman, Michael J.

2012-01-01

Sudden cardiac death (SCD) is one of the most common causes of death in developed countries, with most SCDs involving the elderly, and structural heart disease evident at autopsy. Each year, however, thousands of sudden deaths involving individuals younger than 35 years of age remain unexplained after a comprehensive medicolegal investigation that includes an autopsy. In fact, several epidemiologic studies have estimated that at least 3% and up to 53% of sudden deaths involving previously healthy children, adolescents, and young adults show no morphologic abnormalities identifiable at autopsy. Cardiac channelopathies associated with structurally normal hearts such as long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT), and Brugada syndrome (BrS) yield no evidence to be found at autopsy, leaving coroners, medical examiners, and forensic pathologists only to speculate that a lethal arrhythmia might lie at the heart of a sudden unexplained death (SUD). In cases of autopsy-negative SUD, continued investigation through either a cardiologic and genetic evaluation of first- or second-degree relatives or a molecular autopsy may elucidate the underlying mechanism contributing to the sudden death and allow for identification of living family members with the pathogenic substrate that renders them vulnerable, with an increased risk for cardiac events including syncope, cardiac arrest, and sudden death. PMID:22307399

Reflex syncope, anxiety level, and family history of cardiovascular disease in young women: case-control study.

PubMed

Zyśko, D; Szewczuk-Bogusławska, M; Kaczmarek, M; Agrawal, A K; Rudnicki, J; Gajek, J; Melander, O; Sutton, R; Fedorowski, A

2015-02-01

Anxiety is an emotion, which stimulates sympathetic nervous outflow potentially facilitating vasovagal reflex syncope (VVS) but reports on anxiety levels in patients with VVS are sparse. We studied anxiety levels in young women (21-40 years) referred for unexplained transient loss of consciousness (TLOC), and age-matched female controls with or without past history of TLOC (≈probable VVS). Referred patients underwent head-up tilt (HUT) according to current ESC Guidelines. State and Trait Anxiety Inventory questionnaire evaluated anxiety levels plus a questionnaire explored risk factors for cardiovascular disease (CVD). Sixty-five of 91 women were diagnosed with VVS on HUT. Among 549 controls, 223 (40.6%) reported at least one episode of TLOC. State-anxiety level in patients with VVS undergoing HUT (42.4 ± 9.3) was higher compared with both controls with (38.3 ± 10.2; P < 0.01) and without past TLOC history (35.9 ± 9.8; P < 0.001). Trait anxiety in patients with VVS (42.7 ± 8.4), and controls with TLOC history (42.4 ± 8.4) was higher compared with controls without TLOC history (39.7 ± 8.5; P < 0.01). In the logistic regression using controls without TLOC as reference, both VVS diagnosis and past history of TLOC were associated with family history of CVD [odds ratio (OR) 2.4, 95% confidence interval (CI), 1.3-4.4; P = 0.007, and 2.3, 1.4-3.6; P = 0.001, respectively], and this association was independent of anxiety level. Trait anxiety and family history of CVD are increased in both young women with VVS and controls with history of TLOC. However, the height of anxiety level does not explain CVD heredity and other mechanisms may link syncope with CVD. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

Massive immunoglobulin treatment in women with four or more recurrent spontaneous primary abortions of unexplained aetiology.

PubMed

Yamada, H; Kishida, T; Kobayashi, N; Kato, E H; Hoshi, N; Fujimoto, S

1998-09-01

The aim of this trial was to investigate the efficacy of massive i.v. immunoglobulin (MIVIg) treatment for women with a history of recurrent spontaneous abortion (RSA) due to unexplained aetiology. The study included nine women (11 pregnancies) with a history of four or more consecutive RSA with unexplained aetiology and no live births. The mean number of fetal losses was 4.5 (range 4-6 abortions). Over the course of 5 days, immunoglobulin (20 g/day) was infused i.v. at gestational weeks 4-7. No additional infusions were carried out. Two pregnancies out of the 11 conceptions resulted in missed abortions at gestational weeks 6 and 7 respectively. Mosaicism (46XX/ 48XX, +16, +20), and tetraploidy (92XXXX) were found by chromosome analyses of the two aborti. Eight out of the other nine pregnancies resulted in full term deliveries of healthy neonates. One pregnancy developed intrauterine growth retardation and fetal distress, resulting in a premature delivery (30 gestational weeks) by Caesarean section. Thus, excluding the two abortions with chromosome aberrations, the MIVIg treatment was effective in all nine pregnancies of RSA women with unexplained aetiology. This MIVIg treatment (100 g administered in early gestation) may be a beneficial alternative to previous IVIg infusion methods, and should be further evaluated in a multicentric, placebo-controlled study, employing a larger number of homogeneous patients who fall into a high risk category of first trimester abortions.

How revealing are insertable loop recorders in pediatrics?

PubMed

Frangini, Patricia A; Cecchin, Frank; Jordao, Ligia; Martuscello, Maria; Alexander, Mark E; Triedman, John K; Walsh, Edward P; Berul, Charles I

2008-03-01

An insertable loop recorder (ILR) in patients with infrequent syncope or palpitations may be useful to decide management strategies, including clinical observation, medical therapy, pacemaker, or implantable cardioverter defibrillator (ICD). We sought to determine the diagnostic utility of the Reveal ILR (Medtronic, Inc., Minneapolis, MN, USA) in pediatric patients. Retrospective review of clinical data, indications, findings, and therapeutic decision in 27 consecutive patients who underwent ILR implantation from 1998-2007. The median age was 14.8 years (2-25 years). Indications were syncope in 24 patients and recurrent palpitations in three. Overall, eight patients had structural heart disease (six congenital heart disease, one hypertrophic cardiomyopathy, one Kawasaki), five had previous documented ventricular arrhythmias with negative evaluation including electrophysiology study, and three patients had QT prolongation. Tilt testing was performed in 10 patients, of which five had neurocardiogenic syncope but recurrent episodes despite medical therapy. After median three months (1-20 months), 17 patients presented with symptoms and the ILR memory was analyzed in 16 (no episode stored in one due to full device memory), showing asystole or transient atrioventricular (AV) block (2), sinus bradycardia (6), or normal sinus rhythm (8). Among asymptomatic patients, 3/10 had intermittent AV block or long pauses, automatically detected and stored by the ILR. In 19 of 20 patients, ILR was diagnostic (95%) and five subsequently underwent pacemaker implantation, while seven patients remained asymptomatic without ILR events. Notably, no life-threatening events were detected. The ILR was explanted in 22 patients after a median of 22 months, two due to pocket infection, 12 for battery depletion and eight after clear documentation of nonmalignant arrhythmia. The ILR in pediatrics is a useful adjunct to other diagnostic studies. Patient selection is critical as the ILR should not be utilized for malignant arrhythmias. A diagnosis is attained in the majority of symptomatic patients, predominantly bradyarrhythmias including pauses and intermittent AV block.

An Association Study of the SLC19A1 Gene Polymorphisms/Haplotypes with Idiopathic Recurrent Pregnancy Loss in an Iranian Population.

PubMed

Mohtaram, Shirin; Sheikhha, Mohammad Hasan; Honarvar, Negar; Sazegari, Ali; Maraghechi, Neda; Feizollahi, Zahra; Ghasemi, Nasrin

2016-05-01

The genetics of folate metabolism is one of the most significant mechanisms influencing fetal growth and may underlie some cases of unexplained recurrent miscarriage. Reduced folate carrier 1, encoded by the SLC19A1 gene, is a transporter of folate. Folate deficiency and elevated levels of homocysteine could be disadvantageous for the female reproductive system health. Thus, the balance between homocysteine and folate status can be used to measure the risk of recurrent pregnancy loss. The purpose of this study was to determine the association between -43T>C, 80G>A, and 696C>T polymorphisms of the SLC19A1 gene in 147 women who had unexplained recurrent miscarriage in comparison with 150 healthy women. Amplification refractory mutation system-polymerase chain reaction was used to genotype the molecular polymorphisms of this gene. The results indicated that the -43T>C single nucleotide of the SLC19A1 gene was significantly associated with a risk of recurrent miscarriage in Iranian women (p < 0.05). No significant association was observed for the other two polymorphisms. The haplotype frequency distribution of -43C/80G/696C, -;43C/80G/696T, -43C/80G, and 80G/696T was significantly different in patients than controls, which may represent a novel risk factor for idiopathic recurrent pregnancy loss. Polymorphisms and haplotypes of the SLC19A1 gene can be considered risk factors for idiopathic recurrent pregnancy loss.

Water administration and the risk of syncope and pre-syncope during blood donation: a randomized clinical trial

PubMed Central

van den Berg, Karin; Lam, Jameson; Bruhn, Roberta; Custer, Brian; Murphy, Edward L

2012-01-01

Background Blood centers rely heavily upon adolescent donors to meet blood demand, but pre-syncope and syncope are more frequent in younger donors. Studies have suggested administration of water prior to donation may reduce syncope and/or pre-syncope in this group. Study design and methods We conducted a randomized, controlled trial to establish the effect of pre-loading with 500ml of water on the rate of syncope and pre-syncope in adolescent donors. School collection sites in Eastern Cape Province of South Africa were randomized to receive water or not. Incidence of syncope and pre-syncope was compared between randomization groups using multivariable logistic regression. Results Of 2,464 study participants, 1,337 received water and 1,127 did not; groups differed slightly by gender and race. Syncope or pre-syncope was seen in 23 (1.7%) of the treatment and 18 (1.6%) of the control arm subjects. After adjusting for race, gender, age and donation history, there was no difference in outcome between the water versus no water arms (adjusted odds ratio (OR) = 0.80 (95% CI 0.42–1.53). Black donors had 7-fold lower odds of syncope or pre-syncope than their white counterparts (adjusted OR 0.14, 95% CI 0.04–0.47). Conclusion Preloading adolescent donors with 500ml of water did not have a major effect in reducing syncope and pre-syncope in South African adolescent donors. Our adolescent donors had a lower overall syncope and pre-syncope rate than similar populations in the USA, limiting the statistical power of the study. We confirmed much lower rates of syncope and pre-syncope among young Black donors. PMID:22486209

Risk Factors and Causes of Syncope

MedlinePlus

... Risk Factors & Causes of Syncope Risk Factors for Cardiovascular Syncope The risk of cardiovascular syncope increases with ... Long QT syndrome and Brugada Syndrome Signs of Cardiovascular Syncope Cardiovascular syncope usually is sudden. There may ...

Screening for Addison's disease in patients with type 1 diabetes mellitus and recurrent hypoglycaemia.

PubMed

Likhari, Taruna; Magzoub, Saeed; Griffiths, Melanie J; Buch, Harit N; Gama, R

2007-06-01

Addison's disease may present with recurrent hypoglycaemia in subjects with type 1 diabetes mellitus. There are no data, however, on the prevalence of Addison's disease presenting with recurrent hypoglycaemia in patients with diabetes mellitus. Three year retrospective study of diabetic patients with "unexplained" recurrent hypoglycaemia investigated with a short Synacthen test to exclude adrenocortical insufficiency. 95 patients with type 1 diabetes mellitus were studied. Addison's disease was identified as the cause of recurrent hypoglycaemia in one patient with type 1 diabetes mellitus. Addison's disease is a relatively rare but remedial cause of recurrent hypoglycaemia in patients with type 1 diabetes mellitus. A low threshold for investigating patients with type 1 diabetes mellitus and recurrent hypoglycaemia to detect Addison's disease is therefore suggested.

Skin test reactivity to female sex hormones in women with primary unexplained recurrent pregnancy loss.

PubMed

Ellaithy, Mohamed I; Fathi, Hesham M; Farres, Mohamed N; Taha, Marwa S

2013-09-01

The objective was to examine the hypothesis that primary unexplained recurrent pregnancy loss might be associated with an inappropriate immunologically mediated response to progesterone and/or estrogen. This prospective study included 47 women with two or more documented consecutive early pregnancy losses of unknown etiology, and no previous history of deliveries. Intradermal skin testing was performed in the luteal phase of the cycle (days 16-20) using estradiol benzoate, progesterone, and a placebo of refined sesame oil. Immediate (20 min) and late (24h and 1 week) skin test readings for all cases were compared with those of 12 parous women of comparable age with no history of spontaneous miscarriages, premenstrual disorders, pregnancy, or sex hormone-related allergic or autoimmune diseases. Main outcome measure was skin test reactivity to estradiol and/or progesterone. Immediate skin test reactivity to both hormones was observed among half of the cases at 20 min. A papule after 24h, which persisted for up to 1 week, was observed among 32 (68.1%) and 34 (72.3%) cases at the sites of estrogen and progesterone injection, respectively. 55.3% of cases had combined skin test reactivity to both estradiol and progesterone at 1 week. All women in the control group showed absence of skin test reactivity for both estradiol and progesterone at 20 min, 24h, and 1 week. None of the subjects in either group showed skin test reactivity to placebo. There is an association between primary unexplained recurrent pregnancy loss and skin test reactivity to female sex hormones. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

'Cardiogenic vertigo'--true vertigo as the presenting manifestation of primary cardiac disease.

PubMed

Newman-Toker, David E; Camargo, Carlos A

2006-03-01

A 90-year-old woman presented to a hospital emergency department with a brief loss of consciousness that was heralded by spinning vertigo lasting approximately 2 min. She had a long history of intermittent brief episodes of rotatory vertigo, presyncope, and non-vertiginous dizziness, occurring either with or without loss of consciousness. Although initially attributed to symptomatic carotid artery stenosis, these episodes persisted, despite surgical restoration of carotid artery blood flow 1 year after her first syncope. Her medical history was otherwise notable for hypertension, mild depression and a gradual decline in gait and balance function attributed to left hip arthritis and older age. Bedside history and examination, non-contrast head CT scan, electrocardiogram, transthoracic echocardiogram, and bedside cardiac telemetry. Sick sinus syndrome or severe reflex bradycardia with asystole causing recurrent, episodic vertigo, presyncope, non-vertiginous dizziness and syncope (Stokes-Adams attacks). Placement of a temporary pacing wire, followed by surgical implantation of a single-chamber ventricular (VVI) pacemaker.

The Metabolic Basis of Cystinosis

DTIC Science & Technology

1981-05-12

glucose, amino acids and other organic acids appear. The present- ing symptoms of the disease— polyuria , polydipsia and recurrent unexplained fevers are... polyuria and polydypsia which results make children with the disease extremely susceptible to dehydration. This vulnerability to dehydration explains

A study on phthalate metabolites, bisphenol A and nonylphenol in the urine of Chinese women with unexplained recurrent spontaneous abortion

DOE Office of Scientific and Technical Information (OSTI.GOV)

Peng, Fanli

Humans are widely exposed to phthalates, bisphenol A and nonylphenol owing to the ubiquitous use of these chemicals in consumer products. Increasing attention has been paid to exposure to phthalates, bisphenol A and nonylphenol because of their potential adverse effects on human fertility. A validated method was developed to investigate the three classes of environmental estrogen, mentioned above, in the urine of Chinese women of Nanjing area with unexplained recurrent spontaneous abortion. Solid-phase extraction coupled with ultra performance liquid chromatography–tandem mass spectrometry (UPLC-MS/MS) was used. In this method, amounts of bisphenol A (BPA), nonylphenol (NP) and four phthalate metabolites, mono-n-butylmore » phthalate (MBP), mono-isobutyl phthalate (MiBP), mono-benzyl phthalate (MBzP) and mono-2-ethylhexyl phthalate (MEHP), along with their isotope labeled internal standards, were measured using UPLC-MS/MS operated in negative electrospray ionization multiple reaction monitoring mode. The limits of detection were 0.3 ng/mL for the four phthalate metabolites, and 0.5 ng/mL for bisphenol A and nonylphenol. For women with unexplained recurrent spontaneous abortion, the mean concentrations of MBP, MiBP, MBzP, MEHP, BPA and 4-n-NP were 6.52±6.04, 5.51±4.19, 0.53±0.42, 10.12±4.16, 7.13±7.42, 0.41±0.49 ng/mL (mean±SD), respectively. For the control group, the mean concentrations of the corresponding analytes were 4.15±3.57, 2.96±3.30, 0.46±0.49, 6.50±2.81, 4.43±2.23,0.48±0.43 ng/mL (mean±SD), respectively. Levels of MiBP and MEHP were significantly different between the two groups, using Wilcoxon rank sum tests. This method can be applied in epidemiological studies to explore the association between exposure to environmental estrogens and relevant adverse outcomes. - Highlights: • Studied on the exposure level of six analytes in Chinese women with unexplained recurrent spontaneous abortion. • Differences in MEHP and MiBP urine levels were found between case and control groups. • A robust UPLC-MS/MS method was established for detecting phthalate monoesters, bisphenol A and nonylphenol. • An excellent solid-phase extraction method was established for urine.« less

No evidence for mutations in NLRP7, NLRP2 or KHDC3L in women with unexplained recurrent pregnancy loss or infertility.

PubMed

Aghajanova, L; Mahadevan, S; Altmäe, S; Stavreus-Evers, A; Regan, L; Sebire, N; Dixon, P; Fisher, R A; Van den Veyver, I B

2015-01-01

Are mutations in NLRP2/7 (NACHT, LRR and PYD domains-containing protein 2/7) or KHDC3L (KH Domain Containing 3 Like) associated with recurrent pregnancy loss (RPL) or infertility? We found no evidence for mutations in NLRP2/7 or KHDC3L in unexplained RPL or infertility. Mutations in NLRP7 and KHDC3L are known to cause biparental hydatidiform moles (BiHMs), a rare form of pregnancy loss. NLRP2, while not associated with the BiHM pathology, is known to cause recurrent Beckwith Weidemann Syndrome (BWS). Ninety-four patients with well characterized, unexplained infertility were recruited over a 9-year period from three IVF clinics in Sweden. Blood samples from 24 patients with 3 or more consecutive miscarriages of unknown etiology were provided by the Recurrent Miscarriage Clinic at St Mary's Hospital, London, UK. Patients were recruited into both cohorts following extensive clinical studies. Genomic DNA was isolated from peripheral blood and subject to Sanger sequencing of NLRP2, NLRP7 and KHDC3L. Sequence electropherograms were analyzed by Sequencher v5.0 software and variants compared with those observed in the 1000 Genomes, single nucleotide polymorphism database (dbSNP) and HapMap databases. Functional effects of non-synonymous variants were predicted using Polyphen-2 and sorting intolerant from tolerant (SIFT). No disease-causing mutations were identified in NLRP2, NLRP7 and KHDC3L in our cohorts of unexplained infertility and RPL. Due to the limited patient size, it is difficult to conclude if the low frequency single nucleotide polymorphisms observed in the present study are causative of the phenotype. The design of the present study therefore is only capable of detecting highly penetrant mutations. The present study supports the hypothesis that mutations in NLRP7 and KHDC3L are specific for the BiHM phenotype and do not play a role in other adverse reproductive outcomes. Furthermore, to date, mutations in NLRP2 have only been associated with the imprinting disorder BWS in offspring and there is no evidence for a role in molar pregnancies, RPL or unexplained infertility. This study was funded by the following sources: Estonian Ministry of Education and Research (Grant SF0180044s09), Enterprise Estonia (Grant EU30020); Mentored Resident research project (Department of Obstetrics and Gynecology, Baylor College of Medicine); Imperial NIHR Biomedical Research Centre; Grant Number C06RR029965 from the National Center for Research Resources (NCCR; NIH). No competing interests declared. © The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

An update in recurrent spontaneous abortion.

PubMed

Pandey, Manoj Kumar; Rani, Reena; Agrawal, Suraksha

2005-07-01

Recurrent spontaneous abortion (RSA) is defined as three or more consecutive pregnancy losses prior to the 20th week of gestation. The etiology of recurrent spontaneous abortion is often unclear and may be multifactorial, with much controversy regarding diagnosis and treatment. Reasonably accepted etiologic causes include, genetics, anatomical, endocrine, placental anomalies, hormonal problems, infection, smoking and alcohol consumption, exposure to environmental factors, psychological trauma and stressful life event, certain coagulation and immunoregulatory protein defects. Detection of an abnormality in any of these areas may result into specific therapeutic measures, with varying degrees of success. However, the majority of cases of RSA remains unexplained and is found to be associated with certain autoimmune (APA, ANA, ACA, ATA, AECA) and alloimmune (APCA, Ab2, MLR-Bf) antibodies that may play major role in the immunologic failure of pregnancy and may lead to abortion. Alteration in the expression of HLA-G molecules, T-helper-1 (Th-1) pattern of cytokines and natural killer (NK) cells activity may also induce abortion. Various forms of treatment like antithrombotic therapies such as aspirin and heparin, intravenous immunoglobulin (IVIg) therapy, immunotherapy with paternal lymphocytes and vitamin D3 therapy are effective mode of treatment for unexplained cause of fetal loss in women with RSA.

Familial predisposition to vasovagal syncope.

PubMed

Negrusz-Kawecka, Marta; Bańkowski, Tomasz; Tabin, Mateusz; Paprocka, Magdalena; Mercik, Agnieszka; Misztal, Jowita; Nowak, Piotr; Zysko, Dorota; Gajek, Jacek

2012-06-01

A handful of studies suggest a familial predisposition to vasovagal syncope (WS) but the scope of information available to date is poor. The aim of our study was to evaluate the prevalence of vasovagal syncope and its familial occurrence in the young. The studied group consisted of 281 women and 111 men, aged 18-32 years. Forty-seven percent of the population had one brother or sister, and the mean number of individuals per family was 4.4 +/- 1.0. The questionnaire consisted of 30 questions regarding syncopal history. Syncope was reported in 32.1% of the patients studied (36.7% in women vs. 20.7% in men; P < 0.05), 29.1% of mothers, 16.8% of fathers, 30.9% of sisters and 14.2% of brothers. Logistic regression analysis revealed that positive history regarding the syncope in the whole group of students was related to the female gender (OR 2.17; CI: 1.28-3.7), the history of a syncope in mother (OR 1.74; CI: 1.09-2.78) and the history of a syncope in father (OR 2.22; CI: 1.28-3.86; P < 0.001). A positive history of syncope in male relatives increases the risk of syncope in men and women, whereas a positive history of syncope in female relatives increases the risk of syncope in women only. Female gender independently of the family history increases the risk of syncope. The genetics of the vasovagal syncope could be polygenic but the mechanisms of a transmission remain unclear to date.

Syncope paradox in the outcome of patients with pulmonary thromboembolism: short-term and midterm outcome.

PubMed

Seyyedi, Seyyed-reza; Jenab, Yaser; Tokaldany, Masoumeh Lotfi; Shirani, Shapoor; Sadeghian, Saeed; Jalali, Arash

2016-01-01

We compare the early and midterm outcomes of pulmonary thromboembolism (PTE) in patients with and without syncope in our single-center registry. Between December 2006 and May 2013, 351 consecutive patients (mean age = 60.21 ± 16.91 years, 55.3% male) with confirmed acute symptomatic PTE were divided in with and without syncope groups. Groups were compared in terms of the effect of syncope on 30-day mortality and adverse events, and mortality in a median follow-up time of 16.9 months. From 351 patients, 39 (11.1%) had syncope and 312 (88.9%) did not. Syncope group had less frequently chest pain (30.8% vs 51.4%; P value = 0.015). Also, the rates of 30-day adverse events and mortality were 12.8% and 5.1% for the group with syncope, and 14.4% and 10.3% for the group without syncope, respectively, with no significant difference. At follow up, 65 patients died and mortality was 18.5% for 351 patients (5.1% in the group with syncope and 20.2% for the other group). After adjustment for confounding factors, the effect of syncope on 30-day adverse events and mortality remained non-significant and on the midterm mortality was significant, showing that the presence of syncope was associated with lower midterm mortality (P value = 0.038). Among PTE patients in our registry, 11.1% presented with syncope. Relationship between syncope and 30-day adverse events and mortality remained non-significant after adjustments for other factors. However, in midterm follow up, patients with syncope were significantly at decreased risk of mortality compared to those without syncope. © 2014 John Wiley & Sons Ltd.

Parent and Child Psychological Factors in Pediatric Syncope and Other Somatic Symptoms

ERIC Educational Resources Information Center

Blount, Ronald L.; Morris, Julie A. B.; Cheng, Patricia S.; Campbell, Robert M.; Brown, Ronald T.

2004-01-01

The authors examined associations among parental and child adjustment, child syncope, somatic, and school problems. Participants were children (N = 56) ages 7-18 years with syncope. Measures included syncope severity, parental distress, and children's internalizing symptoms. For children diagnosed negative for neurocardiogenic syncope (NCS), their…

Clinical and electroencephalographic features of carotid sinus syncope induced by internal carotid artery angioplasty.

PubMed

Martinez-Fernandez, E; García, F Boza; Gonzalez-Marcos, J R; Peralta, A Gil; Garcia, A Gonzalez; Deya, A Mayol

2008-02-01

Carotid sinus syncope may occur acutely during internal carotid artery angioplasty (CA). We performed this study to investigate the clinical, electroencephalographic (EEG), and hemodynamic features of carotid sinus syncope induced by CA. Between 1992 and 2003, clinical, EEG, and cardiovascular monitoring was performed in 359 consecutive patients undergoing CA. Carotid sinus reaction (CSR) and syncope occurred in 62.7% and 18.6% of the procedures, respectively. CSR and syncopal spells were classified into cardioinhibitory, vasodepressor, and mixed type. Syncope occurred more frequently in patients with cardioinhibitory CSR (P < .001). The odds ratios for the risk of syncope in patients with cardioinhibitory CSR and vasodepressor/mixed CSR were 6.9 and 1.4, respectively. Sixty-one patients had cardioinhibitory syncope; 7 had the vasodepressor/mixed type. Thirteen spells were not related to cardiovascular disturbances. This last syncope subtype was significantly associated with brain hemodynamic disturbances, including a decrease in cerebral vasoreactivity (P = .04) and the absence of function of both communicating arteries (P = .03). Convulsive movements resembling supplementary sensorimotor seizures occurred in 79% of patients who experienced syncopal spells. EEG changes were more prominent in patients with cardioinhibitory syncope. Syncope occurs frequently in patients undergoing CA and can be misdiagnosed as seizures. The most frequent mechanism was a cardioinhibitory response. Cerebral hemodynamic disturbances may play a crucial role in the pathophysiology of syncope with normal sinus rhythm and normotension. Moreover, direct depression of the CNS following carotid sinus distension is likely to be involved.

Clinical observation of lymphocyte active immunotherapy in 380 patients with unexplained recurrent spontaneous abortion.

PubMed

Chen, Jian-Ling; Yang, Jian-Ming; Huang, Ya-Zhe; Li, Ying

2016-11-01

This study aims to investigate the clinical curative effect of lymphocyte active immunotherapy (LAI) on unexplained recurrent spontaneous abortion (RSA). A total of 749 RSA patients who received medical service in our hospital from October 2009 to June 2013 were enrolled into this study. These patients were randomly divided into two groups: LAI group (treatment group) and routine progesterone for maintenance tocolysis group (control group). A comparative analysis on the pregnancy outcomes in these two groups was conducted. Abortion rate was significantly lower in the LAI group than in the control group (P<0.05). Furthermore, pregnancy success rates were 89.7% and 32.2% in patients who received LAI and routine progesterone for maintenance tocolysis, respectively, and the difference was statistically significant (P<0.05). Our analysis suggested that LAI can treat RSA effectively and has an excellent clinical effect. Furthermore, the detection of blocking antibodies showed a positive prediction on pregnancy outcome. Copyright © 2016 Elsevier B.V. All rights reserved.

Antinuclear autoantibodies and pregnancy outcome in women with unexplained recurrent miscarriage.

PubMed

Ticconi, Carlo; Pietropolli, Adalgisa; Borelli, Barbara; Bruno, Valentina; Piccione, Emilio; Bernardini, Sergio; Di Simone, Nicoletta

2016-11-01

To investigate whether antinuclear autoantibodies (ANA) could be related to the outcome of the successive pregnancy in women with unexplained recurrent miscarriage (uRM). Circulating ANA were measured by indirect immunofluorescence in 86 women with uRM before pregnancy, repeated in the first trimester of the successive gestation and correlated with pregnancy outcome. Forty-one women were ANA- and 45 were ANA+ before pregnancy. No relation was found between pre-pregnancy ANA status and the outcome of the successive pregnancy. However, when these women were monitored at 7th week during their pregnancy for ANA, of the 22 ANA+ women who remained ANA+ seven miscarriages (31.8%) were observed, whereas all of the 23 ANA+ women who became ANA- had pregnancies ongoing beyond the 20th week without miscarriage. ANA status could have a role in uRM. Disappearance of ANA in early pregnancy could have a favorable prognostic value in the successive pregnancy. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

[Comparison of curative effect and serum electrolytes between different oral rehydration salts in treatment of neurally mediated syncope children].

PubMed

Zhang, Wenhua; Zou, Runmei; Xu, Yi; Wang, Cheng

2018-05-28

To compare the curative effect and the changes of serum electrolytes between oral rehydration salts (ORS) I and ORS III treatment in neurally mediated syncope children.
 Methods: The children with the symptom of unexplained syncope and pre-syncope were collected in Second Xiangya Hospital from May 2014 to May 2017. After head-up tilt test (HUTT), their serum electrolytes levels were examined. Children who were positive in the HUTT received ORS (ORS I or ORS III) and health education. Subjects were randomly divided into an ORS I group (n=27) and an ORS III group (n=49).
 Results: There was no statistical significance in sex, age, height, body mass, initial diagnosis and re-diagnosis interval between the 2 groups (P>0.05); the total efficiency after ORS III and ORS I 
treatment were 79.59% and 62.96%, respectively, with no statistical significance (χ2=2.483, P>0.05); the HUTT negative conversion rate after ORS III and ORS I treatment were 51.02% and 48.16%, respectively, with no statistical significance (χ2=0.058, P>0.05); before treatment, the serum sodium [(140.20±2.26) mmol/L vs (138.39±2.72) mmol/L; t=2.856, P<0.05] in the ORS III group was higher than that in the ORS I group, the serum phosphorus [(1.46±0.19) mmol/L 
vs (1.65±0.29) mmol/L; t=3.146, P<0.05] in the ORS III group was lower than that in the ORS I 
group; after treatment, the serum sodium [(140.31±2.01) mmol/L vs (138.88±2.08) mmol/L; 
t=2.692, P<0.05] and serum calcium [(2.31±0.09) mmol/L vs (2.24±0.11) mmol/L; t=2.696, P<0.05] in the ORS III group were higher than those in the ORS I group, the serum phosphorus [(1.45±0.16) mmol/L vs (1.61±0.25) mmol/L; t=3.128, P<0.05] in the ORS III group was lower than that in the ORS I group; after ORS III treatment, there was no statistical significance in serum electrolytes between HUTT positive group and HUTT negative group (P>0.05); after ORS I treatment, the serum calcium [(2.29±0.10) mmol/L vs (2.19±0.10) mmol/L; t=2.501, P<0.05] and serum phosphorus [(1.71±0.24) mmol/L vs (1.50±0.21) mmol/L; t=2.392, P<0.05] in HUTT positive group were higher than those in HUTT negative group. There was no statistical significance in serum sodium, potassium, magnesium, and chloride (P>0.05); there was no statistical significance in serum electrolytes between pre-treatment and post-treatment in the ORS I group and the ORS III 
group (P>0.05); there was no statistical significance in serum electrolytes between vasovagal syncope and postural orthostatic tachycardia syndrome in the ORS I group and the ORS III 
group before ORS treatment (P>0.05). 
 Conclusion: The ORS III and ORS I have the similar efficacy in the treatment of children with neurally mediated syncope. ORS III is easier to be accepted by children than ORS I, with better compliance.

[Approach to syncope in the elderly].

PubMed

Erdoğan, Okan

2017-09-01

Elderly syncope currently accounts a substantial number of emergency admissions. Unfortunately, in elderly syncope we are faced with major difficulties while providing diagnostic and therapeutic decisions. It is quite necessary to distinguish between syncope and non-syncopal causes which create further difficulties during diagnostic work-up because of co-morbid conditions and poly-pharmacy used by the elderly. The present article aims to describe causes of elderly syncope and its differential diagnosis as well as tips and tricks during diagnostic process.

Cerebrovascular and cardiovascular variability interactions investigated through conditional joint transfer entropy in subjects prone to postural syncope.

PubMed

Bari, Vlasta; De Maria, Beatrice; Mazzucco, Claudio Enrico; Rossato, Gianluca; Tonon, Davide; Nollo, Giandomenico; Faes, Luca; Porta, Alberto

2017-05-01

A model-based conditional transfer entropy approach was exploited to quantify the information transfer in cerebrovascular (CBV) and cardiovascular (CV) systems in subjects prone to develop postural syncope. Spontaneous beat-to-beat variations of mean cerebral blood flow velocity (MCBFV) derived from a transcranial Doppler device, heart period (HP) derived from surface electrocardiogram, mean arterial pressure (MAP) and systolic arterial pressure (SAP) derived from finger plethysmographic arterial pressure device were monitored at rest in supine position (REST) and during 60° head-up tilt (TILT) in 13 individuals (age mean  ±  standard deviation: 28  ±  9 years, min-max range: 18-44 years, 5 males) with a history of recurrent episodes of syncope (SYNC) and in 13 age- and gender-matched controls (NonSYNC). Respiration (R) obtained from a thoracic belt was acquired as well and considered as a conditioning signal in transfer entropy assessment. Synchronous sequences of 250 consecutive MCBFV, HP, MAP, SAP and R values were utilized to estimate the information genuinely transferred from MAP to MCBFV (i.e. disambiguated from R influences) and vice versa. Analogous indexes were computed from SAP to HP and vice versa. Traditional time and frequency domain analyses were carried out as well. SYNC subjects showed an increased genuine information transfer from MAP to MCBFV during TILT, while they did not exhibit the expected rise of the genuine information transfer from SAP to HP. We conclude that SYNC individuals featured an impaired cerebral autoregulation visible during TILT and were unable to activate cardiac baroreflex to cope with the postural challenge. Traditional frequency domain markers based on transfer function modulus, phase and coherence functions were less powerful or less specific in typifying the CBV and CV controls of SYNC individuals. Conditional transfer entropy approach can identify the impairment of CBV and CV controls and provide specific clues to identify subjects prone to develop postural syncope.

Understanding and Managing Neurally Mediated Syncope in the Adolescent

ERIC Educational Resources Information Center

Rollinson, Nancy L.

2005-01-01

Syncope and near-syncopal symptoms are common events in the adolescent population. Syncope is defined as the transient loss of postural tone and consciousness with spontaneous recovery. Although most syncopal events are benign, they can generate extreme anxiety in the adolescent and his or her family. The reoccurrence of these events can have a…

Fall about laughing: a case of laughter syncope.

PubMed

Bragg, Matthew J

2006-01-01

Laughter syncope is an unusual but recognized form of situational syncope likely to have a similar pathophysiological origin to tussive syncope. There are few case reports of this syndrome in the literature. Patients, as in this case, might present initially to the ED, and laughter should be considered among the numerous differentials for syncope.

Inherited and acquired thrombophilia in Indian women experiencing unexplained recurrent pregnancy loss.

PubMed

Patil, Rucha; Ghosh, Kanjaksha; Vora, Sonal; Shetty, Shrimati

2015-10-01

The most frequently hypothesized cause of unexplained recurrent pregnancy loss (RPL) refers to a defective maternal haemostatic response leading to uteroplacental thrombosis. Approximately 20% women suffering from pregnancy loss (PL) are associated with autoimmune disorders and more than 50% remain idiopathic after common traditional investigations. The present study aims to investigate the prevalence of different genetic and acquired thrombophilia markers in a large series of Indian women with RPL. Such studies will help analyze the markers which pose maximum risk and help in the appropriate treatment in subsequent pregnancies. The study comprised of 587 women with no apparent etiological causes of RPL and 115 healthy women controls. p values were calculated with two tailed Fisher's exact test; statistical significance was assumed at p<0.05, 95% confidence interval. Relative risks were also calculated. Among genetic thrombophilia, the risk of PL was highest with protein S deficiency (16%, p=0.006) followed by plasminogen activator inhibitor-1 4G/4G (23%, p=0.007) polymorphism. Among acquired markers, the risk of PL was the highest in women with anti-cardiolipin antibodies (24%, p=0.0001), followed by anti-annexin V antibodies (23%, p=0.0009) and lupus anticoagulants (8%, p=0.02). Thrombophilia, inherited and acquired, is an important contributing factor in unexplained RPL and should be screened in the order of its prevalence. Copyright © 2015 Elsevier Inc. All rights reserved.

The risk for syncope and presyncope during surgery in surgeons and nurses.

PubMed

Rudnicki, Jerzy; Zyśko, Dorota; Gajek, Jacek; Kuliczkowski, Wiktor; Rosińczuk-Tonderys, Joanna; Zielińska, Dominika; Terpiłowski, Łukasz; Agrawal, Anil Kumar

2011-11-01

Surgeons and nurses are exposed to orthostatic stress. To assess the lifetime incidence of syncopal and presyncopal events during surgery in operation room staff and reveal the predicting factors. The study included 317 subjects (161 F, 156 M) aged 43.9 ± 9.6; 216 surgeons and 101 instrumenters. The study included filling of an anonymous questionnaire on the syncope and presyncope history. At least one syncopal event during operation was reported by 4.7% and presyncope by 14.8% of the studied population. All but one subject reported prodromal symptoms before syncope. In the medical history, syncope outside the operating room was reported by 11% of the studied group. Syncope and presyncope during operation was related to syncope in the medical history outside the operation room, respectively: odds ratio (OR) 20.2 95% confidence interval (CI): 2.0-70.5 and OR 10.8; CI: 5.0-23.4 and to presyncope in the medical history, respectively: OR 23.5; CI: 7.4-74.4 OR 8.9; CI: 3.6-11.2 (P < 0.001). (1) Syncope and presyncope may occur during surgery in the staff of the operating room. (2) Syncope in the operating room is usually preceded by prodromal symptoms and has vasovagal origin. (3) Both lower then expected occurrence of syncope in the operating room staff and absence of any difference between genders in this regard indicate preselection in the process of choosing profession and specialization. (4) Syncope and presyncope outside the operating room in medical history increases the risk of syncope and presyncope inside the operation room.

Fainiting (Syncope)

MedlinePlus

... sudden cardiac arrest and death. Types of Syncope Cardiovascular syncope – The most dangerous but rare type of ... or by structural damage to the heart. Non-cardiovascular syncope – The most common type (also called vasovagal ...

[Evaluation of psychological fear in children undergoing head-up tilt test].

PubMed

Chu, Wei-Hong; Wu, Li-Jia; Wang, Cheng; Lin, Ping; Li, Fang; Zhu, Li-Ping; Ran, Jing; Zou, Run-Mei; Liu, De-Yu

2014-03-01

To investigate the effects of different tilt angles of head-up tilt test (HUTT) and different responses to HUTT on the psychological fear in children undergoing the test. HUTT was performed on children with unexplained syncope or pre-syncope (107 cases: 52 males and 55 females), aged 5.5-17.8 years (mean 12.0±2.8 years). All subjects were randomly assigned to undergo HUTT at an angle of 60°, 70° or 80°; the negative cases underwent sublingual nitroglycerin-provocation HUTT at the same tilt angle. The Wong-Baker Faces Pain Rating Scale was used for self-assessment of psychological fear in subjects during HUTT at the end point of the test. The positive rate, hemodynamic changes and distribution of response types showed no significant differences between children at tilt angles of 60°, 70° and 80° (P>0.05). The greater the tilt angle, the higher the degree of psychological fear in children undergoing the test, but there were no significant differences between them (P>0.05). The degree of psychological fear in children who showed a positive response to HUTT (n=76) was significantly higher than that in children who showed a negative response (n=31) (P<0.01). HUTT can cause psychological fear in children undergoing the test, and the degree of psychological fear increases in children tested at tilt angles from 60° to 80°, but the differences have no statistical significance. A positive response to HUTT can significantly increase the psychological fear in children.

Is pacemaker therapy the right key to patients with vasovagal syncope?

PubMed

Radovanović, Nikola N; Kirćanski, Bratislav; Raspopović, Srdjan; Pavlović, Siniša U; Jovanović, Velibor; Milašinović, Goran

2016-01-01

Vasovagal syncope is the most common type of reflex syncope. Efficacy of cardiac pacing in this indication has not been the subject of many studies and pacemaker therapy in patients with vasovagal syncope is still controversial. This study aimed to assess the efficacy and safety of pacing therapy in treatment of patients with vasovagal syncope, to determine contribution of new therapeutic models in increasing its success, and to identify risk factors associated with a higher rate of symptoms after pacemaker implantation. A retrospective study included 30 patients with pacemaker implanted due to vasovagal syncope in the Pacemaker Center, Clinical Center of Serbia, between November 2003 and June 2014. Head-up tilt test was performed to diagnose vasovagal syncope. Patients with cardioinhibitory and mixed type of disease were enrolled in the study. Mean age was 48.1 ± 11.1 years and 18 (60%) patients were men. Mean follow-up period was 5.9 ± 3.0 years. Primarily, implantable loop recorder was implanted in 10 (33.3%) patients. Twenty (66.7%) patients presented cardioinhibitory and 10 (33.3%) mixed type of vasovagal syncope. After pacemaker implantation, 11 (36.7%) patients had syncope. In multiple logistic regression analysis we showed that syncope is statistically more likely to occur after pacemaker implantation in patients with mixed type of vasovagal syncope (p = 0.018). There were two (6.7%) perioperative surgical complications. Pacemaker therapy is a safe treatment for patients with vasovagal syncope, whose efficacy can be improved by strict selection of patients. We showed that symptoms occur statistically more often in patients with mixed type of disease after pacemaker implantation.

Characteristics of Patients Referred to a Pediatric Infectious Diseases Clinic With Unexplained Fever.

PubMed

Statler, Victoria A; Marshall, Gary S

2016-09-01

Older case series established diagnostic considerations for children meeting a priori definitions of fever of unknown origin (FUO). No recent study has examined the final diagnoses of children referred for unexplained fever. This study was conducted with a retrospective chart review of patients referred to a pediatric infectious diseases clinic from 2008 to 2012 for unexplained fever. Sixty-nine of 221 patients were referred for "prolonged" unexplained fever. Ten of these were not actually having fever, and 11 had diagnoses that were readily apparent at the initial visit. The remaining 48 were classified as having FUO. The median duration of reported fever for these patients was 30 days; 15 had a diagnosis made, 5 of which were serious. None of the serious FUO diagnoses were infections. Of 152 patients with "recurrent" unexplained fever, 92 had an "intermittent" fever pattern, and most of these had sequential, self-limited viral illnesses or no definitive diagnosis made. Twenty of the 60 patients with a "periodic" fever pattern were diagnosed with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. Overall, 166 patients either were not having fever, had self-limited illnesses, or ultimately had no cause of fever discovered. Only 12 had a serious illness, 2 of which were infections (malaria and typhoid fever). Most children referred with unexplained fever had either self-limited illnesses or no specific diagnosis established. Serious diagnoses were unusual, suggesting that these diagnoses rarely present with unexplained fever alone, or that, when they do, the diagnoses are made by primary care providers or other subspecialists. © The Author 2015. Published by Oxford University Press on behalf of the Pediatric Infectious Diseases Society. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

[Syncope: electrocardiogram and autonomic function tests].

PubMed

Uribe, William; Baranchuk, Adrián; Botero, Federico

2016-12-23

Syncope represents one of the most frequent reasons for consultation in the emergency department. A proper identification will allow a precise etiologic approach and the optimization of delivery of health resources.
Once knowing the classification of syncope; it is the clinical interrogatory what enables to discriminate which of these patients present with a neurogenic mediated syncope or a cardiac mediated syncope. The use of diagnostic methods such as the tilt test, will clarify what type of neurally mediated syncope predominates in the patient.
The electrocardiogram is the cornerstone in the identification of those patients who had a true episode of self-limited or aborted sudden death as the first manifestation of their syncope, a fact which provides prognostic and therapeutic information that will impact the morbidity and mortality.

Risk of cardiac disease and observations on lack of potential predictors by clinical history among children presenting for cardiac evaluation of mid-exertional syncope.

PubMed

Miyake, Christina Y; Motonaga, Kara S; Fischer-Colbrie, Megan E; Chen, Liyuan; Hanisch, Debra G; Balise, Raymond R; Kim, Jeffrey J; Dubin, Anne M

2016-06-01

This study aimed to evaluate the incidence of cardiac disorders among children with mid-exertional syncope evaluated by a paediatric cardiologist, determine how often a diagnosis was not established, and define potential predictors to differentiate cardiac from non-cardiac causes. Study design We carried out a single-centre, retrospective review of children who presented for cardiac evaluation due to a history of exertional syncope between 1999 and 2012. Inclusion criteria included the following: (1) age ⩽18 years; (2) mid-exertional syncope; (3) electrocardiogram, echocardiogram and an exercise stress test, electrophysiology study, or tilt test, with exception of long QT, which did not require additional testing; and (4) evaluation by a paediatric cardiologist. Mid-exertional syncope was defined as loss of consciousness in the midst of active physical activity. Patients with peri-exertional syncope immediately surrounding but not during active physical exertion were excluded. A total of 60 patients met the criteria for mid-exertional syncope; 32 (53%) were diagnosed with cardiac syncope and 28 with non-cardiac syncope. A majority of cardiac patients were diagnosed with an electrical myopathy, the most common being Long QT syndrome. In nearly half of the patients, a diagnosis could not be established or syncope was felt to be vasovagal in nature. Neither the type of exertional activity nor the symptoms or lack of symptoms occurring before, immediately preceding, and after the syncopal event differentiated those with or without a cardiac diagnosis. Children with mid-exertional syncope are at risk for cardiac disease and warrant evaluation. Reported symptoms may not differentiate benign causes from life-threatening disease.

Clinical relevance of syncope and presyncope induced by tilt testing.

PubMed

Zyśko, Dorota; Gajek, Jacek; Koźluk, Edward; Agrawal, Anil Kumar; Smereka, Jacek; Checiński, Igor

2009-08-01

The authors investigated the relation between presyncope and syncope induced by tilt testing (HUTT) and demographics, medical history and HUTT data.The demographics, syncopal burden, data regarding the spontaneous syncope and reproduction of symptoms during HUTT were compared among patients with induced syncope and presyncope. The study group consisted of 574 patients (371 women, 203 men), aged 43.7 +/- 18.5 years. Patients with syncope induced by HUTT (418 patients, 63.9% women) had a higher number of syncopal episodes in their medical history. Stepwise logistic regression revealed that syncope provocation was independently related to the cardiodepressive type of neurocardiogenic reaction (OR 7.8, CI 4.2-14.4, P < 0.001), NTG use (OR 1.7, CI: 1.0-2.7, P < 0.05), the reproduction of the symptoms during HUTT (OR 2.0, CI: 1.3-3.1, P < 0.01) and the higher number of syncopal episodes (OR 2.0, CI: 1.3-3.0, P < 0.01). In patients with positive HUTT during a passive phase it was related to the cardiodepressive type of reaction (OR 26.5, CI: 5.9-118.5, P < 0.001). In the group with positive HUTT after NTG syncope was related to the cardiodepressive type (OR 5.7, CI: 2.9-11.2, P < 0.001), vasovagal history (OR 2.0, CI: 1.2-3.3, P < 0.01), reproduction of the spontaneous symptoms (OR 1.9, CI: 1.1-3.1, P < 0.05) and higher number of syncopal episodes (OR 2.1, CI: 1.3-3.3, P < 0.01). Syncope is more frequently a HUTT outcome than presyncope. The provocation of syncope in the passive phase of HUTT depends only on the cardiodepressive type of neurocardiogenic reaction. The induction of presyncope after nitroglycerin provocation is related to the possibility of a false positive reaction.

Syncope management unit: evolution of the concept and practice implementation.

PubMed

Shen, Win K; Traub, Stephen J; Decker, Wyatt W

2013-01-01

Syncope, a clinical syndrome, has many potential causes. The prognosis of a patient experiencing syncope varies from benign outcome to increased risk of mortality or sudden death, determined by the etiology of syncope and the presence of underlying disease. Because a definitive diagnosis often cannot be established immediately, hospital admission is frequently recommended as the "default" approach to ensure patient's safety and an expedited evaluation. Hospital care is costly while no studies have shown that clinical outcomes are improved by the in-patient practice approach. The syncope unit is an evolving practice model based on the hypothesis that a multidisciplinary team of physicians and allied staff with expertise in syncope management, working together and equipped with standard clinical tools could improve clinical outcomes. Preliminary data have demonstrated that a specialized syncope unit can improve diagnosis in a timely manner, reduce hospital admission and decrease the use of unnecessary diagnostic tests. In this review, models of syncope units in the emergency department, hospital and outpatient clinics from different practices in different countries are discussed. Similarities and differences of these syncope units are compared. Outcomes and endpoints from these studies are summarized. Developing a syncope unit with a standardized protocol applicable to most practice settings would be an ultimate goal for clinicians and investigators who have interest, expertise, and commitment to improve care for this large patient population. Copyright © 2013 Elsevier Inc. All rights reserved.

Worsening of symptoms before presentation with vasovagal syncope.

PubMed

Sheldon, Robert S; Sheldon, Aaron G; Serletis, Anna; Connolly, Stuart J; Morillo, Carlos A; Klingenheben, Thomas; Krahn, Andrew D; Koshman, Mary-Lou; Ritchie, Debbie

2007-09-01

Much of the natural history of vasovagal syncope is unknown. We determined whether patients presenting for care have had a recently worsened syncope frequency. We compared 208 subjects in the referral-based Prevention of Syncope Trial (POST) and 122 subjects who fainted > or =1 in a community survey study. Their mean ages and gender proportions were similar. The POST population had a higher median lifetime syncope frequency (1.16 vs 0.12 spells/year, P < 0.0001) and more subjects began fainting at age > or =35 years (26% vs 6%, P < 0.0001). In POST, the median frequency of syncopal spells in the preceding year was higher than in all previous years (3 vs 0.57, P < 0.0001). POST subjects presented sooner after their first spell (median 11.0 vs 16.8 years, P = 0.0002), and after their last spell (median 0.3 vs 7.4 years, P < 0.0001). POST subjects > or =35 years old had a shorter history than similar community-survey subjects (2.8 vs 14.9 y, P < 0.0001) and presented earlier after their first syncopal spell than POST subjects with a younger onset of syncope (median 2.8 vs 14.7 y, P < 0.0001), despite having fewer faints (median 6 vs 10, P = 0.0002). Many syncope patients present for care after a recent worsening of their frequency of syncope.

Double Stranded Sperm DNA Breaks, Measured by Comet Assay, Are Associated with Unexplained Recurrent Miscarriage in Couples without a Female Factor

PubMed Central

Ribas-Maynou, Jordi; García-Peiró, Agustín; Fernandez-Encinas, Alba; Amengual, Maria José; Prada, Elena; Cortés, Pilar; Navarro, Joaquima; Benet, Jordi

2012-01-01

It is known that sperm samples from recurrent pregnancy loss (RPL) couples have an increase in their sperm DNA fragmentation (SDF), but no studies have been performed in order to identify differences between single stranded SDF (ssSDF) and double stranded SDF (dsSDF) in these patients. This could be relevant because the type of DNA damage could have different effects. Semen samples were classified attending their clinical status: 25 fertile donors and 20 RPL patients with at least two unexplained first trimester miscarriages. SDF was analysed using alkaline and neutral Comet assay, SCD test and pulsed-field gel electrophoresis (PFGE), and ROC analysis including data from 105 more infertile patients (n = 150) was performed to establish predictive threshold values. SDF for alkaline and neutral Comet, and the SCD test was analysed in these categories of individuals. Data revealed the presence of two subgroups within fertile donors. The values obtained were 21.10±9.13, 23.35±10.45 and 12.31±4.31, respectively, for fertile donors with low values for both ssSDF and dsSDF; 27.86±12.64, 80.69±12.67 and 12.43±5.22, for fertile donors with low ssSDF and high dsSDF; and 33.61±15.50, 84.64±11.28 and 19.28±6.05, for unexplained RPL patients, also showing a low ssSDF and high dsSDF profile. This latter profile was seen in 85% of unexplained RPL and 33% of fertile donors, suggesting that it may be associated to a male risk factor for undergoing RPL. ROC analysis regarding recurrent miscarriage set the cut-off value at 77.50% of dsDNA SDF. PFGE for low ssSDF and high dsSDF profile samples and positive controls treated with DNase, to induce dsDNA breaks, showed a more intense band of about 48 kb, which fits the toroid model of DNA compaction in sperm, pointing out that some nuclease activity may be affecting their sperm DNA in RPL patients. This work identifies a very specific SDF profile related to the paternal risk of having RPL. PMID:23028579

Frequent Visitors: Somatization in School-Age Children and Implications for School Nurses

ERIC Educational Resources Information Center

Shannon, Robin Adair; Bergren, Martha Dewey; Matthews, Alicia

2010-01-01

There is a gap in the nursing literature regarding children who frequently visit school nurses' offices with recurrent unexplained physical symptoms. A review of the scientific health literature was undertaken to examine the clinical presentation, associated variables, and implications for school nurses regarding children who are frequent school…

Masquerading bundle branch block as a presenting manifestation of complete atrioventricular block that caused syncope.

PubMed

Jiao, Zhenyu; Tian, Ying; Yang, Xinchun; Liu, Xingpeng

2017-10-01

A 59-year-old male patient was admitted with the main complaints of stuffiness and shortness of breath. An ECG from precordial leads on admission showed masquerading bundle branch block. Syncope frequently occurred after admission. During syncope episodes, ECG telemetry showed that the syncope was caused by intermittent complete atrioventricular block, with the longest RR interval lasting for 4.36 s. At the gap of syncope, ECG showed complete right bundle branch block accompanied by alternation of left anterior fascicular block and left posterior fascicular block. The patient was implanted with a dual-chamber permanent pacemaker. Follow-up of 9 months showed no reoccurrence of syncope.

Bedside heart type fatty acid binding protein (H-FABP): Is an early predictive marker of cardiac syncope.

PubMed

Sonmez, Bedriye Muge; Ozturk, Derya; Yilmaz, Fevzi; Altinbilek, Ertugrul; Kavalci, Cemil; Durdu, Tamer; Hakbilir, Oktay; Turhan, Turan; Ongar, Murat

2015-11-01

To determine the value of bedside heart-type fatty acid binding protein in diagnosis of cardiac syncope in patients presenting with syncope or presyncope. The prospective study was conducted at Ankara Numune Training and Research Hospital, Ankara, Turkey, between September 1, 2010, and January 1, 2011, and comprised patients aged over 18 years who presented with syncope or presyncope. Patients presenting to emergency department within 4 hours of syncope or presyncope underwent a bedside heart-type fatty acid binding protein test measurement. SPSS 16 was used for statistical analysis. Of the 100 patients evaluated, 22(22%) were diagnosed with cardiac syncope. Of them, 13(59.1%) patients had a positive and 9(40.9%) had a negative heart-type fatty acid binding protein result. Consequently, the test result was 12.64 times more positive in patients with cardiac syncope compared to those without. Bedside heart-type fatty acid binding protein, particularly at early phase of myocardial injury, reduces diagnostic and therapeutic uncertainity of cardiac origin in syncope patients.

Chronic endometritis in women with recurrent pregnancy loss and recurrent implantation failure: prevalence and role of office hysteroscopy and immunohistochemistry in diagnosis.

PubMed

Bouet, Pierre-Emmanuel; El Hachem, Hady; Monceau, Elise; Gariépy, Gilles; Kadoch, Isaac-Jacques; Sylvestre, Camille

2016-01-01

To determine the prevalence of chronic endometritis (CE) in patients with recurrent implantation failure (RIF) after IVF and unexplained recurrent pregnancy loss (RPL). Prospective observational study between November 2012 and March 2015. University-affiliated private IVF clinic. Women with RIF after IVF (group 1) and unexplained RPL (group 2). Office hysteroscopy followed by an endometrial biopsy was performed as part of the workup for RIF and RPL. The diagnosis of CE was histologically confirmed using immunohistochemistry stains for syndecan-1 (CD138). The prevalence of CE in each group and the sensitivity/specificity of office hysteroscopy in the diagnosis of CE. Ninety-nine patients were included (46 in group 1 and 53 in group 2). The mean age was 36.3 ± 4.9 years in group 1 and 34.5 ± 4.9 years in group 2. Five biopsies were uninterpretable (three in group 1 and two in group 2) because of insufficient specimen. The prevalence of CE was 14% (6/43) in group 1 and 27% (14/51) in group 2. The sensitivity and specificity of office hysteroscopy in the diagnosis of CE were 40% (8/20) and 80% (59/74), respectively. We found a high prevalence of immunohistochemically confirmed CE in women with RIF and RPL. Office hysteroscopy is a useful diagnostic tool but should be complemented by an endometrial biopsy for the diagnosis of CE. NCT01762098. Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Expression of retinoid-related orphan receptor (ROR)γt on NK22 cells in the peripheral blood and uterine endometrium of women with unexplained recurrent pregnancy loss and unexplained infertility.

PubMed

Fuchinoue, Kohei; Fukui, Atsushi; Chiba, Hitomi; Kamoi, Mai; Funamizu, Ayano; Taima, Ayako; Fukuhara, Rie; Mizunuma, Hideki

2016-11-01

Recently, NK22 cells, a subset of interleukin (IL)-22-producing natural killer (NK) cells, were identified. We have previously reported the higher percentage of NK22 cells in women suffering recurrent pregnancy loss (RPL). Moreover, we have also reported lower expression of NKp46, a kind of natural cytotoxicity receptor (NCR), on NK cells and the changes of NK cell producing cytokines in women who experience RPL. NK22 cells express NCRs, such as NKp44 or NKp46. Retinoid-related orphan receptor γt (RORγt) is known as a regulator of NK22 cells; however, in NK22 cells of peripheral blood (PB) and the uterine endometrium (UE), the relationship between NCRs and RORγt is unclear. We investigate RORγt expression NK22 cells in the PB and UE of women with unexplained infertility (uI) or unexplained RPL (uRPL). Lymphocytes were extracted from PB and UE, derived from women with uI or uRPL. Expression of RORγt and NCRs in NK cells and NK cell-produced cytokines were analyzed by flow cytometry. CD56 + /NKp46 + /RORγt + cells were positively correlated with CD56 + /IL-22 + cells in both PB and UE. CD56 bright /NKp46 bright /RORγt + cells were significantly higher in uRPL than in uI, and endometrial CD56 bright /NKp46 bright /RORγt + cells were positively correlated with PB. In UE, CD56 bright /RORγt + cells were negatively correlated with CD56 bright /interferon-γ + and CD56 bright /tumor necrosis factor-α + cells of uRPL. RORγt may be associated with NK22 cells in reproduction. Particularly, higher expression of RORγt may be associated with elevated NK22 cells in uRPL. © 2016 Japan Society of Obstetrics and Gynecology.

Is subclinical hypothyroidism associated with lower live birth rates in women who have experienced unexplained recurrent miscarriage?

PubMed

van Dijk, Myrthe M; Vissenberg, Rosa; Bisschop, Peter H; Dawood, Feroza; van Wely, Madelon; Goddijn, Mariëtte; Farquharson, Roy G

2016-12-01

Thyroid disorders have been associated with recurrent miscarriage. Little evidence is available on the influence of subclinical hypothyroidism on live birth rates. In this cohort study, women who had experienced miscarriage and subclinical hypothyroidism (defined as thyroid-stimulating hormone >97.5th percentile mU/l with a normal thyroxine level) were investigated; the control group included women who had experienced recurrent miscarriage and normal thyroid function. Multivariable logistic regression was used to investigate the association of subclinical hypothyroidism. Data were available for 848 women; 20 (2.4%) had subclinical hypothyroidism; 818 women (96%) had euthyroidism; and 10 (1.2%) had overt hypothyroidism. The live birth rate was 45% in women with subclinical hypothyroidism and 52% in euthyroid women (OR 0.69, 95% CI 0.28 to 1.71). The ongoing pregnancy rate was 65% versus 69% (OR 0.82, 95% CI 0.32 to 2.10) and the miscarriage rate was 35% versus 28% (OR 1.43, 95% CI 0.56 to 3.68), respectively. No differences were found when thyroid stimulating hormone 2.5 mU/l was used as cut-off level to define subclinical hypothyroidism. In women with unexplained miscarriage, no differences were found in live birth, ongoing pregnancy and miscarriage rates between women with subclinical hypothyroidism and euthyroid women. Copyright © 2016. Published by Elsevier Ltd.

The pattern of activation of the sympathetic nervous system during tilt-induced syncope.

PubMed

Zyśko, Dorota; Gajek, Jacek; Sciborski, Ryszard; Smereka, Jacek; Checiński, Igor; Mazurek, Walentyna

2007-04-01

A 49-year-old patient with a history of situational syncope and minimal electrocardiographic signs of accessory pathway is described. The evidence for pre-excitation was present only during the sympathetic activation caused by exercise testing and isoprenaline infusion. This phenomenon served as an indicator of significant adrenergic drive to the heart after the tilt-induced syncope. The meaning of the observed electrocardiographic changes in the course of neurocardiogenic reaction and its contribution to the understanding of the sympatho-vagal balance during vasovagal syncope is discussed. The lack of preexcitation signs during syncope and its appearance several seconds after the syncope-related sinus pause indicates sympathetic withdrawal before and shortly after the asystole. The possible pathophysiological mechanisms are discussed.

Is there a prognostic relevance of electrophysiological studies in bundle branch block patients?

PubMed

Bogossian, Harilaos; Frommeyer, Gerrit; Göbbert, Kornelius; Hasan, Fuad; Nguyen, Quy Suu; Ninios, Ilias; Mijic, Dejan; Bandorski, Dirk; Hoeltgen, Reinhard; Seyfarth, Melchior; Lemke, Bernd; Eckardt, Lars; Zarse, Markus

2017-08-01

The present European guidelines suggest a diagnostic electrophysiological (EP) study to determine indication for cardiac pacing in patients with bundle branch block and unexplained syncope. We evaluated the prognostic relevance of an EP study for mortality and the development of permanent complete atrioventricular (AV) block in patients with symptomatic bifascicular block and first-degree AV block. The HV interval is a poor prognostic marker to predict the development of permanent AV block in patients with symptomatic bifascicular block (BFB) and AV block I°. Thirty consecutive patients (mean age, 74.8 ± 8.6 years; 25 males) with symptomatic BFB and first-degree AV block underwent an EP study before device implantation, according to current guidelines. For 53 ± 31 months, patients underwent yearly follow-up screening for syncope or higher-degree AV block. Thirty patients presented with prolonged HV interval during the EP study (mean, 82.2 ± 20.1 ms; range, 57-142 ms), classified into 3 groups: group 1, <70 ms (mean, 62 ± 4 ms; range, 57-67 ms; n = 7), group 2, >70 to ≤100 ms (mean, 80 ± 8 ms; range, 70-97 ms; n = 18), and group 3, >100 ms (mean, 119 ± 14 ms; range, 107-142 ms; n = 5). According to the guidelines, patients in groups 2 and 3 received a pacemaker. The length of the HV interval was not associated with the later development of third-degree AV block or with increased mortality. Our present study suggests that an indication for pacemaker implantation based solely on a diagnostic EP study with prolongation of the HV interval is not justified. © 2017 Wiley Periodicals, Inc.

Tilt testing results are influenced by tilt protocol.

PubMed

Zyśko, Dorota; Fedorowski, Artur; Nilsson, David; Rudnicki, Jerzy; Gajek, Jacek; Melander, Olle; Sutton, Richard

2016-07-01

It is unknown how the return to supine position influences duration of loss of consciousness (LOC) and cardioinhibition during tilt test. Retrospective analysis of two datasets containing records of patients who underwent tilt testing for unexplained syncope in two centres was performed. Patients, totalling 1232, were included in the study: 262 in a Swedish centre and 970 patients in a Polish centre. In Sweden, tilt table with tilt-down time (TDT) of 18 s was used (Group II). In Poland, two different tilt tables were used, one of them with TDT of 10 s (Group I, n = 325), and the other with TDT of 47 s (Group III, n = 645). Cardioinhibitory reflex occurred most frequently in Group III, whereas number of pauses >3 s, frequency of very long asystole ≥30 s, and the total duration of pauses >3 s demonstrated a trend to increase from Group I to III. Duration of LOC in Groups II and III was significantly longer compared with Group I (32.0 and 33.7 s vs. 16.4 s). In the multivariate-adjusted regression model, cardioinhibitory reflex was predicted by tilt-table model (odds ratio per model with increasing TDT: 1.40; 95% confidence interval, 1.19-1.64; P < 0.0001), whereas LOC duration was longer with increasing TDT (P < 0.0001) and age (P < 0.0001). Longer TDT during induced vasovagal syncope increases the prevalence of cardioinhibitory reflex and prolongs the duration of LOC. Tilt-down time does not affect asystolic pause duration but delay may lead to occurrence of multiple pauses, higher frequency of very long asystole, and longer total asystole duration. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

Cardiac Iodine-123-Meta-Iodo-Benzylguanidine Uptake in Carotid Sinus Hypersensitivity.

PubMed

Tan, Maw Pin; Murray, Alan; Hawkins, Terry; Chadwick, Thomas J; Kerr, Simon R J; Parry, Steve W

2015-01-01

Carotid sinus syndrome is the association of carotid sinus hypersensitivity with syncope, unexplained falls and drop attacks in generally older people. We evaluated cardiac sympathetic innervation in this disorder in individuals with carotid sinus syndrome, asymptomatic carotid sinus hypersensitivity and controls without carotid sinus hypersensitivity. Consecutive patients diagnosed with carotid sinus syndrome at a specialist falls and syncope unit were recruited. Asymptomatic carotid sinus hypersensitivity and non-carotid sinus hypersensitivity control participants recruited from a community-dwelling cohort. Cardiac sympathetic innervation was determined using Iodine-123-metaiodobenzylguanidine (123-I-MIBG) scanning. Heart to mediastinal uptake ratio (H:M) were determined for early and late uptake on planar scintigraphy at 20 minutes and 3 hours following intravenous injection of 123-I-MIBG. Forty-two subjects: carotid sinus syndrome (n = 21), asymptomatic carotid sinus hypersensitivity (n = 12) and no carotid sinus hypersensitivity (n = 9) were included. Compared to the non- carotid sinus hypersensitivity control group, the carotid sinus syndrome group had significantly higher early H:M (estimated mean difference, B = 0.40; 95% confidence interval, CI = 0.13 to 0.67, p = 0.005) and late H:M (B = 0.32; 95%CI = 0.03 to 0.62, p = 0.032). There was, however, no significant difference in early H:M (p = 0.326) or late H:M (p = 0.351) between the asymptomatic carotid sinus hypersensitivity group and non- carotid sinus hypersensitivity controls. Cardiac sympathetic neuronal activity is increased relative to age-matched controls in individuals with carotid sinus syndrome but not those with asymptomatic carotid sinus hypersensitivity. Blood pressure and heart rate measurements alone may therefore represent an over simplification in the assessment for carotid sinus syndrome and the relative increase in cardiac sympathetic innervation provides additional clues to understanding the mechanisms behind the symptomatic presentation of carotid sinus hypersensitivity.

[Dermatological features of auto-inflammatory recurrent fevers].

PubMed

Escudier, A; Mauvais, F-X; Bastard, P; Boussard, C; Jaoui, A; Koskas, V; Lecoq, E; Michel, A; Orcel, M-C; Truelle, P-E; Wohrer, D; Piram, M

2018-02-01

Auto-inflammatory diseases are characterized by unexplained and recurrent attacks of systemic inflammation often involving the skin, joints, or serosal membranes. They are due to a dysfunction or dysregulation of the innate immunity, which is the first line of defense against pathogens. Early recognition of these diseases by the clinician, especially by pediatricians encountering such pathologies in pediatric patients, is primordial to avoid complications. Skin manifestations, common in most auto-inflammatory diseases, are helpful for prompt diagnosis. After a brief physiopathological review, we will describe auto-inflammatory recurrent fevers by their main dermatological presentations: urticarial lesions, neutrophilic dermatoses, panniculitis, other maculopapular eruptions, dyskeratosis, skin vasculitis, and oral aphthous. We finally suggest a decision tree to help clinicians better target genetic exams in patients with recurrent fevers and dermatological manifestations. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Nonlinear effects of respiration on the crosstalk between cardiovascular and cerebrovascular control systems

NASA Astrophysics Data System (ADS)

Bari, Vlasta; Marchi, Andrea; De Maria, Beatrice; Rossato, Gianluca; Nollo, Giandomenico; Faes, Luca; Porta, Alberto

2016-05-01

Cardiovascular and cerebrovascular regulatory systems are vital control mechanisms responsible for guaranteeing homeostasis and are affected by respiration. This work proposes the investigation of cardiovascular and cerebrovascular control systems and the nonlinear influences of respiration on both regulations through joint symbolic analysis (JSA), conditioned or unconditioned on respiration. Interactions between cardiovascular and cerebrovascular regulatory systems were evaluated as well by performing correlation analysis between JSA indexes describing the two control systems. Heart period, systolic and mean arterial pressure, mean cerebral blood flow velocity and respiration were acquired on a beat-to-beat basis in 13 subjects experiencing recurrent syncope episodes (SYNC) and 13 healthy individuals (non-SYNC) in supine resting condition and during head-up tilt test at 60° (TILT). Results showed that JSA distinguished conditions and groups, whereas time domain parameters detected only the effect of TILT. Respiration affected cardiovascular and cerebrovascular regulatory systems in a nonlinear way and was able to modulate the interactions between the two control systems with different outcome in non-SYNC and SYNC groups, thus suggesting that the analysis of the impact of respiration on cardiovascular and cerebrovascular regulatory systems might improve our understanding of the mechanisms underpinning the development of postural-related syncope.

The clinical relevance of the duration of loss of consciousness provoked by tilt testing.

PubMed

Zyśko, Dorota; Gajek, Jacek; Kozluk, Edward; Agrawal, Anil Kumar; Smereka, Jacek; Checiński, Igor

2010-04-01

The authors assessed the relationships between the duration of loss of consciousness (dLOC) during tilt testing-induced syncope (TTS) and demographics, medical history as well as tilt testing results. Previous research focused on the relevance of the type of neurocardiogenic reaction during TTS. The importance of dLOC has not been assessed so far. The study was carried out in 274 patients with suspected neurally mediated syncope and total loss of consciousness during tilt testing. The syncope burden, demographics, and data regarding spontaneous syncope orTTS were compared between group I with dLOC > or =47 seconds and group 2 with dLOC <47 seconds. Medical history revealed that patients in group I had more syncopal spells, more frequent syncope-related traumatic injuries, urine incontinence, jerking movements and typical vasovagal history than in group 2. Moreover, group I patients had more frequently a cardioinhibitory type of reaction and a shorter active phase duration. In addition, they manifested more frequent accompanying cerebral hypoperfusion signs and reproduction of symptoms during TTS than patients in group 2. The loss of consciousness during tilt testing-induced syncope differs in terms of duration among patients with neurally mediated syncope. The dLOC during TTS is associated with medical history and tilt-testing data which confirm the vasovagal aetiology of spontaneous events. The longer dLOC suggests deeper cerebral haemodynamic disturbances during either spontaneous or provoked syncope.

Syncopation, Body-Movement and Pleasure in Groove Music

PubMed Central

Witek, Maria A. G.; Clarke, Eric F.; Wallentin, Mikkel; Kringelbach, Morten L.; Vuust, Peter

2014-01-01

Moving to music is an essential human pleasure particularly related to musical groove. Structurally, music associated with groove is often characterised by rhythmic complexity in the form of syncopation, frequently observed in musical styles such as funk, hip-hop and electronic dance music. Structural complexity has been related to positive affect in music more broadly, but the function of syncopation in eliciting pleasure and body-movement in groove is unknown. Here we report results from a web-based survey which investigated the relationship between syncopation and ratings of wanting to move and experienced pleasure. Participants heard funk drum-breaks with varying degrees of syncopation and audio entropy, and rated the extent to which the drum-breaks made them want to move and how much pleasure they experienced. While entropy was found to be a poor predictor of wanting to move and pleasure, the results showed that medium degrees of syncopation elicited the most desire to move and the most pleasure, particularly for participants who enjoy dancing to music. Hence, there is an inverted U-shaped relationship between syncopation, body-movement and pleasure, and syncopation seems to be an important structural factor in embodied and affective responses to groove. PMID:24740381

Syncopation, body-movement and pleasure in groove music.

PubMed

Witek, Maria A G; Clarke, Eric F; Wallentin, Mikkel; Kringelbach, Morten L; Vuust, Peter

2014-01-01

Moving to music is an essential human pleasure particularly related to musical groove. Structurally, music associated with groove is often characterised by rhythmic complexity in the form of syncopation, frequently observed in musical styles such as funk, hip-hop and electronic dance music. Structural complexity has been related to positive affect in music more broadly, but the function of syncopation in eliciting pleasure and body-movement in groove is unknown. Here we report results from a web-based survey which investigated the relationship between syncopation and ratings of wanting to move and experienced pleasure. Participants heard funk drum-breaks with varying degrees of syncopation and audio entropy, and rated the extent to which the drum-breaks made them want to move and how much pleasure they experienced. While entropy was found to be a poor predictor of wanting to move and pleasure, the results showed that medium degrees of syncopation elicited the most desire to move and the most pleasure, particularly for participants who enjoy dancing to music. Hence, there is an inverted U-shaped relationship between syncopation, body-movement and pleasure, and syncopation seems to be an important structural factor in embodied and affective responses to groove.

Laughter-induced syncope.

PubMed

Kim, Alexander J; Frishman, William H

2012-01-01

Reported cases of syncope caused directly by laughter are rare. The common scenario described in a few reports involved episodes of fortuitous laughter, sometimes followed by a short prodrome of lightheadedness, facial flushing, and dizziness, followed by an episode of definite syncope. There were no seizure-like movements, automatisms, or bladder or bowel incontinence. After the syncopal episodes that were seconds in length, the patients regained consciousness, and at that point were fully oriented. These episodes could recur in a similar situation with such laughter. Many of these patients subsequently underwent full syncope workups, without elucidating a primary cardiac or neurologic cause. In this review of laughter-induced syncope, we describe a patient of ours who fit these descriptions. This phenomenon is likely a subtype of benign Valsalva-related syncope, with autonomic reflex arcs coming into play that ultimately result in global cerebral hypoperfusion. Besides the Valsalva produced by a great fit of laughter, laughter itself has its own neuroendocrine and vasculature effects that may play a role.

A new hypothesis of cause of syncope: trigeminocardiac reflex during extraction of teeth.

PubMed

Arakeri, Gururaj; Arali, Veena

2010-02-01

Transient Loss Of Consciousness (TLOC) or vasovagal syncope is well known phenomenon in dental/maxillofacial surgery. Despite considerable study of vasovagal syncope, its pathophysiology remains to be fully elucidated. After having encountered a case of trigeminocardiac reflex after extraction of maxillary first molar we observed and studied 400 extractions under local anesthesia to know the relation between trigeminocardiac reflex and syncope. We make hypothesis that trigeminocardiac reflex which is usually seen under general anesthesia when all sympathetic reflexes are blunted can also occur under local anesthesia during extractions of maxillary molars (dento-cardiac reflex) and mediate syncope.

[Neurohumoral mechanisms for vasovagal syncopes. Part II].

PubMed

Gajek, Jacek; Zyśko, Dorota

2003-04-01

Vasovagal syncope is defined as a reflex loss of consciousness related to reaction to various stimuli as orthostatic stress, pain or emotions connected with loss of muscle postural tone. In the second part of the paper the authors describe the possible role of the particular neurohumoral factors and autonomic nervous system in the development of vasovagal syncope. The studies on the involvement of neurohumoral factors in vasovagal syncope can play a key role in a more precise evaluation of affected patients, long term prophylaxis against syncopal events and may contribute to development of more reliable diagnostic tests.

Vestibular syncope: A disorder associated with drop attack in Ménière's disease.

PubMed

Pyykkö, Ilmari; Manchaiah, Vinaya; Zou, Jing; Levo, Hilla; Kentala, Erna

2018-04-01

Experiments in humans and animals indicate that vestibular influx through vestibular sympathetic reflex is an important and vital part of the regulatory system of circulation. The otolith organ adjusts the circulatory responses through the vestibular sympathetic reflex during an upright stance and may trigger a vasovagal attack of syncope. The aim of the present study was to evaluate the prevalence and association of syncope attacks among patients with Ménière's disease (MD). Vestibular syncope was defined as a sudden and transient loss of consciousness, which subsides spontaneously in people with vestibular disorders and without localizing neurological deficit. During clinical interactions, we encountered 5 patients with syncope during a Tumarkin attack of MD. Thereafter we evaluated data from 952 patients collected with a questionnaire from the Finnish Ménière Association (FMA). The data contained case histories with special attention to Tumarkin attacks, participation restriction, migraines, and syncope attacks. The mean age of the subjects participating in the study was 60.6 years (range 25-75 years). The duration of the disease was on average 9.8 years (range 0.5-35 years). In the current study sample, attacks of syncope were reported by 38 patients (4%) in association with the vertigo attack. Syncope was associated with Tumarkin attacks (X 2 =16.7, p<0.001), migraine (X 2 =7.4, p<0.011), history of ischemic heart disease (X 2 =6.0, p<0.025), and history of cerebrovascular disease (X 2 =11.7, p<0.004). Duration of MD was correlated with syncope. Syncope was provoked by physical strain and environmental pressure, and was associated with impairment of the visual field (i.e., visual blurring). In logistic regression analysis, syncope was significantly associated with Tumarkin attacks (odds ratio 3.2), migraines (odds ratio 2.3) and nausea (odds ratio 1.3). The attack of syncope was experienced as frightening, and general health related quality of life (HRQoL) was significantly worsened. Also, the patients suffered more from fatigue. The current study indicates that patients with MD who suffer from Tumarkin attacks can suffer from syncope. It confirms the role of the otolith organ in controlling the circulatory homeostasis of the body. The actions are mediated through the vestibular sympathetic reflex. Copyright © 2017 Elsevier B.V. All rights reserved.

A debate on the certainty of etiology in a case of syncope.

PubMed

Dan, Anca Rodica; Daha, Ioana; Buzea, C A; Dan, G A

2013-01-01

We present the case of a 47-year-old woman with reccurent syncope. The investigations for establishing the etiology of syncope were extended over 4 years and multiple possible mecahisms for the syncope were identified. Even if the guidelines mention a good diagnostic yield for history and initial evaluation, for some selected cases the initial diagnostic supposition should be revised.

Cardiovascular function in women with recurrent miscarriage, pre-eclampsia and/or intrauterine growth restriction.

PubMed

Mahendru, Amita A; Everett, Thomas R; McEniery, Carmel M; Wilkinson, Ian B; Lees, Christoph C

2013-03-01

To investigate prepregnancy cardiovascular function and risk factors in women with previous pregnancy complications. Thirty-four women with previous normal pregnancy (controls), 26 with unexplained recurrent miscarriage (RM) and 14 with pre-eclampsia (PE) and/or intrauterine growth restriction (IUGR), planning to conceive were recruited. Brachial and central blood pressures (BP), cardiac output (CO), peripheral vascular resistance (PVR), aortic stiffness, blood biochemistry and platelet aggregation were assessed. Women with previous PE/IUGR had higher brachial diastolic BP (78 ± 9 vs 71 ± 7 mmHg; p = 0.03), central systolic BP (107 ± 10 vs 99 ± 8 mmHg; p = 0.03), mean arterial pressure (92 ± 10 vs 84 ± 8 mmHg; p = 0.01) and PVR (1499 ± 300 vs 1250 ± 220 dynes.s(-1) cm(-5); p = 0.005), than the controls. No differences were observed in either cardiovascular function or blood biochemistry in women with unexplained RM compared with the controls. Women with previous PE/IUGR though not with RM had a stronger family history of cardiovascular disease (CVD) than controls. Women with previous PE and/or IUGR had higher BP and PVR compared with controls, which may predispose them to CVD later in life. However, in the absence of underlying vascular pathology, women with unexplained RM did not have abnormal cardiovascular function. Prepregnancy period provides an opportunity to identify cardiovascular risks in relation to previous obstetric history.

Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope.

PubMed

Brignole, Michele; Croci, Francesco; Menozzi, Carlo; Solano, Alberto; Donateo, Paolo; Oddone, Daniele; Puggioni, Enrico; Lolli, Gino

2002-12-04

We hypothesized that isometric arm exercises were able to increase blood pressure (BP) during the phase of impending vasovagal syncope and allow the patient to avoid losing consciousness. Hypotension is always present during the prodromal phase of vasovagal syncope. We evaluated the effect of handgrip (HG) and arm-tensing in 19 patients affected by tilt-induced vasovagal syncope. The study consisted of an acute single-blind, placebo-controlled, randomized, cross-over tilt-table efficacy study and a clinical follow-up feasibility study. In the acute tilt study, HG was administered for 2 min, starting at the time of onset of symptoms of impending syncope. In the active arm, HG caused an increase in systolic blood pressure (SBP) from 92 +/- 10 mm Hg to 105 +/- 38 mm Hg, whereas in the placebo arm SBP decreased from 91 +/- 11 mm Hg to 73 +/- 21 mm Hg (p = 0.008). Heart rate behavior was similar in the two arms. In the active arm, 63% of patients became asymptomatic, versus 11% in the control arm (p = 0.02); conversely, only 5% of patients developed syncope, versus 47% in the control arm (p = 0.01). The patients were trained to self-administer arm-tensing treatment as soon as symptoms of impending syncope occurred. During 9 +/- 3 months of follow-up, the treatment was actually performed in 95/97 episodes of impending syncope (98%) and was successful in 94/95 (99%). No patients suffered injury or other adverse morbidity related to the relapses. Isometric arm contraction is able to abort impending vasovagal syncope by increasing systemic BP. Arm counter-pressure maneuvers can be proposed as a new, feasible, safe, and well accepted first-line treatment for vasovagal syncope.

Vasovagal syncope in medical students and their first-degree relatives.

PubMed

Serletis, Anna; Rose, Sarah; Sheldon, Aaron G; Sheldon, Robert S

2006-08-01

To determine the effect of family history on the likelihood of vasovagal syncope. Sixty-two medical students and 228 first-degree relatives were studied. Vasovagal syncope was ascertained with the Calgary syncope symptom score. The effects of the sex of the subject and parental syncope history on the likelihood of offspring fainting were described using Kaplan-Meier estimates and analysed using proportional hazards regression. The prevalence of vasovagal syncope was 32% and the median age of first faint in those who fainted was 14 years. More females than males fainted [42 vs. 31%; P=0.02; hazard ratio (HR) 1.34 (95% CI 1.07-1.68)]. An individual with two fainting parents was more likely to faint than one with no fainting parents [P<0.0001; HR 3.4 (95% CI 1.7-7.03)]. In the proportional hazards model, offspring of either sex whose mother faints are more likely to faint than those whose mother does not faint [HR 2.86 (95% CI 1.54-5.31)]. Having a father who faints significantly increases the risk of syncope in sons [HR 4.12 (95%CI 1.39-12.31)], but not in daughters [HR 1.18 (95% CI 0.56-3.34)]. Family history and sex of subject are important predictors of vasovagal syncope in offspring.

Genetic mutations of young patients admitted to an emergency department for syncope during sport practice.

PubMed

Gómez Alcaraz, Jorge; Bustamante, José; Corral, Ervigio; Casado Florez, Maria Isabel; Vivas, David; Cañadas-Godoy, Victoria; González Del Castillo, Juan; González Armengol, Juan Jorge; López-Farré, Antonio; Martín Sánchez, Francisco Javier

2018-04-25

To study the frequency of genetic mutations related to genetic heart disease among young patients admitted for syncope during sport practice. A case series study that included patients≤45 years admitted for syncope during sport practice during 2010-2011. We collected demographic and clinical variables, genetic tests mutations and final clinical diagnosis. A genetic test was performed in 46 (76.7%) of 60 patients evaluated. The genetic test was positive in 12 (26%; 95% CI 15.6-40.3) patients; 10 (21.7%) had PKP2 mutation related to arrhythmogenic right ventricular dysplasia mutation, one (2.2%) KCNQ1 mutation and one (2.2%) SCN5A mutation related to channelopathies. The genetic test was positive in 11 (35.5%) cases of undetermined syncope and one (50%) case of cardiac syncope, being negative in all cases with neuromediated syncopes (P=.037). Gene mutations are common in young patients suffering from syncope during sports, especially in those with cardiac or undetermined aetiology. Copyright © 2018 Elsevier España, S.L.U. All rights reserved.

[Syncope and work: role of the occupational physician and global risk stratification].

PubMed

Barbic, F; Angaroni, L; Orlandi, M; Costantino, G; Dipaola, E; Borleri, D; Borchini, R; D'Adda, F; Perego, F; Borella, M; Galli, A; Solbiati, M; Scanella, E; Casazza, G; Seghizzi, P; Furlan, R

2011-01-01

Safety risk for subjects suffering from syncope while working has not been as yet addressed by occupational medicine. The present study was aimed at evaluating a new developed methodology for job tasks risk stratification in patients with syncope. During a work-shop on syncope and occupational risk, 149 occupational physicians (OP) with about 10 years of clinical experience were asked to fulfil a Visual Analogue Scale (VAS) concerning the doctor's estimated potential damage (D) to the worker and the probability of a damage to occur (P) should syncope take place during the job task. Five job tasks characterized by different risk for safety (1, driving; 2, toxic products handling; 3, job performed closed to hot surfaces o free flames; 4, surgical activity; 5, office job) were identified. OP correctly stratified the risk associated to the different job tasks in patients with syncope. Unexpectedly, task #3 was given a risk similar to that obtained in drivers. This might be of paramount clinical and social importance when patients with syncope have to return to their job tasks.

Recurrence risk of ictal asystole in epilepsy.

PubMed

Hampel, Kevin G; Thijs, Roland D; Elger, Christian E; Surges, Rainer

2017-08-22

To determine the recurrence risk of ictal asystole (IA) and its determining factors in people with epilepsy. We performed a systematic review of published cases with IA in 3 databases and additionally searched our local database for patients with multiple seizures simultaneously recorded with ECG and EEG and at least one IA. IA recurrence risk was estimated by including all seizures without knowledge of the chronological order. Various clinical features were assessed by an individual patient data meta-analysis. A random mixed effect logistic regression model was applied to estimate the average recurrence risk of IA. Plausibility of the calculated IA recurrence risk was checked by analyzing the local dataset with available information in chronological order. Eighty patients with 182 IA in 537 seizures were included. Recurrence risk of IA amounted to 40% (95% confidence interval [CI] 32%-50%). None of the clinical factors (age, sex, type and duration of epilepsy, hemispheric lateralization, duration of IA per patient) appeared to have a significant effect on the short-term recurrence risk of IA. When considering the local dataset only, IA recurrence risk was estimated to 30% (95% CI 14%-53%). Information whether IA coincided with symptoms (i.e., syncope) or not was given in 60 patients: 100 out of 142 IAs were symptomatic. Our data suggest that in case of clinically suspected IA, the recording of 1 or 2 seizures is not sufficient to rule out IA. Furthermore, the high short-term recurrence risk favors aggressive treatment, including pacemaker implantation if seizure freedom cannot be achieved. Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

Air Swallowing Caused Recurrent Ileus in Tourette’s Syndrome

PubMed Central

Frye, Richard E.; Hait, Elizabeth J.

2008-01-01

This report describes an adolescent boy who has Tourette’s syndrome and developed a subtle but significant increase in vocal tics after an 8-month respite. The increase in vocal tics was associated with an acute increase in psychological stressors and resulted in recurrent air swallowing, which, in turn, caused abdominal cramping, eructation, and flatus, eventually leading to aeroenteria. Air swallowing was recognized only after a second hospital admission for recurrent ileus. Air swallowing and associated symptoms were mitigated by reinstitution of psychopharmacologic treatment and an increase in the patient’s self-awareness of the air-swallowing behavior. Clinically significant air swallowing has not been described previously in Tourette syndrome or a tic disorder. This case is important for pediatricians and pediatric gastroenterologists because either may be the first to evaluate a child or an adolescent with unexplained recurrent ileus. This report also documents the importance of the connection between the brain and the body. PMID:16651280

Expression of peroxisome proliferator activation receptors (PPARs) and TNFα in placenta tissues in unexplained recurrent pregnancy loss: an immunohistochemical study.

PubMed

Papamitsou, Theodora; Toskas, Alexandros; Papadopoulou, Kyriaki; Economou, Zinon; Sioga, Antonia

2016-09-01

PPAR expression in placenta tissues regulates proinflammatory cytokine production and preserves the quiescence of the uterus during pregnancy. PPAR-γ regulates inflammatory response during gestation while PPAR-δ and TNFα play a central role at implantation, decidualization and placentation. However, their expression levels affect normal pregnancy and may cause gestational complications and miscarriage. The aim of this report is to investigate the relationship of these molecules with unexplained recurrent miscarriage. The miscarriage group was obtained from 12 women, between the ages of 35 to 42 years, who miscarried during the 1st trimester of gestation and controls consisted of 12 healthy women, between the ages of 27 to 39 years, who had electively terminated their pregnancies, during the 1st trimester of gestation. The abortion material was processed and specimens taken were studied using immunohisto-chemical methods. Specimens were taken from decidua basalis and decidua parietalis. Monoclonal antibodies were used against PPAR-γ (Peroxisome Proliferator Activation Receptor γ), PPAR-δ and TNFα (Tumor Necrosis Factor alpha). The results were statistically analyzed with Mann-Whitney test. Our research identified PPAR-γ expression in decidua basalis and decidua parietalis from control group and decidua basalis from miscarriage group. PPAR-δ expression was also identified in both deciduas from both groups. Statistically, no significant change in PPAR-γ and PPAR-δ expression was observed between recurrent miscarriage group and controls. On the contrary, a statistically significant upregulation of TNFα was identified in both deciduas between miscarriage group and controls (p<0.05). Our evidence did not support a possible role of PPARs expression in recurrent pregnancy loss. However, a potential involvement of TNFα in the syndrome was reported. Further research should be performed due to insufficient bibliographic data.

Potential involvement of placental AhR in unexplained recurrent spontaneous abortion.

PubMed

Wu, Y; Chen, X; Chang, X; Huang, Y J; Bao, S; He, Q; Li, Y; Zheng, J; Duan, T; Wang, K

2016-01-01

Recurrent spontaneous abortion (RSA) is a common complication of pregnancy. Recent studies have demonstrated that the aryl hydrocarbon receptor (AhR) might play important roles in establishing and maintaining early pregnancy. In this study, we found that placental AhR protein levels were significantly lower and placental CYP1A1 mRNA levels were higher in unexplained RSA (URSA) patients than in control subjects. The results of immunohistochemical analyzes showed that placental AhR was expressed in syncytiotrophoblast cells and that the level of AhR was markedly lower in these cells in URSA subjects than in control subjects. β-Naphthoflavone (β-NF, an AhR ligand) at 5μM significantly inhibited proliferation and migration in HTR-8/SVneo cells and was associated with the activation of AhR. Moreover, overexpressing AhR in JAR cells significantly increased CYP1A1 mRNA levels and inhibited cell migration. These results indicate that AhR is highly activated in URSA placentas and that the activation of AhR in the placenta might impair trophoblast cell proliferation and migration, possibly leading to the occurrence of URSA. Copyright © 2015 Elsevier Inc. All rights reserved.

Clinical Efficacy of Low Molecular Heparin on Unexplained Recurrent Spontaneous Abortion.

PubMed

Xu, Guang-Li; Hu, Xiao-Fang; Han, Yong-Mei; Wei, Ai-Wu

2018-06-01

To study the clinical effect of low molecular heparin on unexplained recurrent spontaneous abortion (URSA). A total of 120 URSA patients were collected in our hospital from October 2015 to September 2017. They were divided into two groups: control group (n = 60) and observation group (n = 60). The patients in the control group were administered with progesterone and human chorionic gonadotropin, and the observation group with low molecular heparin. Pregnancy outcomes, incidence of complications in pregnancy and adverse drug reactions were compared in the two groups. The pregnancy success rate of patients in the observation group (90.00%) is higher than that in the control group (68.33%) (p < 0.05). The incidence of complications in pregnancy in the observation group (90.00%) is lower than those in the control group (68.33%) (p < 0.05). The incidence of adverse drug reactions between the patients in the observation group (20.00%) and those in the control group (23.33%) showed no significant difference (p > 0.05). Low molecular heparin treatment can improve pregnancy success rate and reduce the incidence of complications in the URSA patients. Low molecular heparin is characterized by safety and reliability and has potential for application in clinic.

Managing the military patient with syncope.

PubMed

Parsons, Iain T; Cox, A T; Mollan, I A; Boos, C J

2015-09-01

Syncope is a relatively common occurrence in military populations. It is defined as a transient loss of consciousness due to global cerebral hypoperfusion, characterised by a rapid onset, short duration and a spontaneous and complete recovery. While the symptom of syncope is easily elicited, discovering the mechanism can be more problematic and may require a plethora of diagnostic tests. The aim of this paper is to review current evidence pertaining to the classification, investigation and management of syncope, from a military perspective. Emphasis is placed on assisting primary healthcare professionals in the assessment and management of syncope, in the UK and on operations, while providing explicit guidance on risk. The occupational limitations required in safely managing patients with syncope are stressed along with the potential long-term limitations. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

G-suited for prevention of syncope in patients with vasovagal syncope: a pilot study.

PubMed

Rasmeehirun, Prayuth; Krittayaphong, Rungroj

2014-03-01

Vasovagal syncope (VVS) represents by far the most common cause of syncope as it is diagnosed in around 50% of all patients that come to an emergency department. Although VVS is not fatal, it can cause an injury. Even serious injuries are not common, but there are reports of serious injuries of up to 5%. There are no current studies that demonstrate the effectiveness of any treatment. Past studies found that an Anti-Gravity suit (G-suit) can increase blood pressure and has been reported to prevent orthostatic hypotension effectively in patients with diabetes. It is possible that the G-suit can prevent VVS. In the present study, the authors assessed the efficacy of G-suit for vasovagal syncope prevention. In this open-label, randomized controlled study, we used the Italian tilt protocol, namely 60 degree passive tilting followed by 0.4 mg nitroglycerin challenge when the passive phase fails to induce syncope. If test was positive, then patient was enrolled. Tilt table test was repeated to compare G-suited and no G-suited to assess efficacy of G-suit for vasovagal syncope prevention. 10 patients were enrolled. There is no difference between the control group and an experimental group. In this study there is no cardio-inhibition vasovagal syncope. Positive tilt table test occurred in 50% of the patients receiving G-suited and 100% in control group (p 0.133). G-suit is unable to prevent syncope in patients with positive tilt table test but the result is not statistically significant. However, the number of patients may be too small.

[Uterine anomalies in women with recurrent pregnancy loss].

PubMed

Galamb, Ádám; Pethő, Boglárka; Fekete, Dávid; Petrányi, Győző; Pajor, Attila

2015-07-05

One percent of couples trying to have children are affected by recurrent miscarriage. These pregnancy losses have different pathogenetic (genetic, endocrine, anatomic, immunologic, microbiologic, haematologic and andrologic) backgrounds, but recurrent miscarriage remains unexplained in more than half of the affected couples. To explore risk factors for recurrent pregnancy loss the authors studied the incidence of anatomic disorders of the uterine cavity occur in Hungarian women with recurrent miscarriage. Medical records of 152 patients with recurrent miscarriage were analyzed retrospectively. In order to explore disorders of the uterine cavity hysteroscopy or 3-dimensional sonography in 132 women, hysterosalpingography in 16 and hysterosalpingo-sonography in 4 patients were used. Incidence of anomalies in the uterine cavity was found in women with recurrent miscarriage to be 15.8%. A variety of the uterine anomalies was found including uterine septum in 6.5%, endometrial polyp in 2.6%, arcuate and bicornuate uteri both in 2% and 2%, submucosal myoma in 1.3 %, and intrauterine synechiae in 1.3%. These findings suggest that morphologic disorder of the uterine cavity is frequent in Hungarian women with recurrent miscarriage. Therefore, assessment of the uterine anatomy is recommended in such patients.

Heart rate variability during head-up tilt test in patients with syncope of unknown origin.

PubMed

Gielerak, Grzegorz; Makowski, Karol; Kramarz, Elzbieta; Cholewa, Marian; Dłuzniewska, Ewa; Roszczyk, Anna; Bogaj, Agnieszka

2002-11-01

Analysis of pathophysiological mechanisms responsible for vaso-vagal reaction reveals a close relationship between neurocardiogenic syncope and the preceding abnormalities of autonomic nervous system (ANS). Therefore, the interest in the assessment of heart rate variability (HRV) for detecting and establishing therapy in patients with syncope due to vaso-vagal mechanism is not surprising. To assess ANS changes during tilt testing in patients with syncope of unknown origin. Forty patients (18 males, mean age 34.8+/-15.8 years) with a history of at least two syncopal episodes during the last 6 months and 24 healthy controls underwent tilt testing. Spectral HRV analysis was performed from ECG recorded 5 min before tilting (period A), 5 min after tilting (period B), and 5 min before syncope (or 20-25 min of tilt test when syncope did not occur) (period C). Tilt test was positive in 23 (58%) patients; 12 (30%) had mixed response, 10 (25%) - vasodepressive, and 1 (3%) - cardioinhibitory reaction. The mean time from tilt to syncope was 22.3 minutes. One (4%) control subject developed syncope. In all groups a decrease of LF and HF power, as well as an increase in the LF/HF ratio in response to tilting were observed. The LF/HF values were significantly different between patients with mixed vaso-vagal reaction and controls (1.9 vs 4.2; p=0.04). In the C-B periods the highest decrease in the HF spectra was found in patients with mixed reaction and was significantly greater than in other patients or controls. Also, patients with mixed reaction had the highest increase in LF values which was significantly more pronounced than in patients with vasodepressive reaction (10139.3 vs 466.9; p=0.003). As a result, the change in LF/HF ratio was positive in patients with mixed reaction, controls and patients with negative result of tilt test, and negative - in patients with vaso-depressive syncope, reaching statistical significance between patients with mixed and vaso-depressive response (2.04 vs -0.51; p=0.03). The pattern of HRV changes during tilt testing depends on the type of vaso-vagal reaction which leads to syncope. The most accurate HRV parameter for identification of patients with reflex syncope is the LF/HF ratio.

Clinical significance of somatic mutation in unexplained blood cytopenia

PubMed Central

Gallì, Anna; Travaglino, Erica; Ambaglio, Ilaria; Rizzo, Ettore; Molteni, Elisabetta; Elena, Chiara; Ferretti, Virginia Valeria; Catricalà, Silvia; Bono, Elisa; Todisco, Gabriele; Bianchessi, Antonio; Rumi, Elisa; Zibellini, Silvia; Pietra, Daniela; Boveri, Emanuela; Camaschella, Clara; Toniolo, Daniela; Papaemmanuil, Elli; Ogawa, Seishi; Cazzola, Mario

2017-01-01

Unexplained blood cytopenias, in particular anemia, are often found in older persons. The relationship between these cytopenias and myeloid neoplasms like myelodysplastic syndromes is currently poorly defined. We studied a prospective cohort of patients with unexplained cytopenia with the aim to estimate the predictive value of somatic mutations for identifying subjects with, or at risk of, developing a myeloid neoplasm. The study included a learning cohort of 683 consecutive patients investigated for unexplained cytopenia, and a validation cohort of 190 patients referred for suspected myeloid neoplasm. Using granulocyte DNA, we looked for somatic mutations in 40 genes that are recurrently mutated in myeloid malignancies. Overall, 435/683 patients carried a somatic mutation in at least 1 of these genes. Carrying a somatic mutation with a variant allele frequency ≥0.10, or carrying 2 or more mutations, had a positive predictive value for diagnosis of myeloid neoplasm equal to 0.86 and 0.88, respectively. Spliceosome gene mutations and comutation patterns involving TET2, DNMT3A, or ASXL1 had positive predictive values for myeloid neoplasm ranging from 0.86 to 1.0. Within subjects with inconclusive diagnostic findings, carrying 1 or more somatic mutations was associated with a high probability of developing a myeloid neoplasm during follow-up (hazard ratio = 13.9, P < .001). The predictive values of mutation analysis were confirmed in the independent validation cohort. The findings of this study indicate that mutation analysis on peripheral blood granulocytes may significantly improve the current diagnostic approach to unexplained cytopenia and more generally the diagnostic accuracy of myeloid neoplasms. PMID:28424163

A Population-Based Cohort Study Evaluating Outcomes and Costs for Syncope Presentations to the Emergency Department.

PubMed

Sandhu, Roopinder K; Tran, Dat T; Sheldon, Robert S; Kaul, Padma

2018-02-01

This study sought to examine outcomes and costs of patients with syncope admitted and discharged from the emergency department (ED). ED visits for syncope are common, yet the impact on health care utilization is relatively unknown. A total of 51,831 consecutive patients presented to the ED with a primary diagnosis of syncope (International Classification of Diseases-9 code 780.2 and International Classification of Diseases-10 code R55) in Alberta, Canada from 2006 to 2014. Outcomes included 30-day syncope ED and hospital readmissions; 30-day and 1-year mortality; and annual inpatient, outpatient, physician, and drug costs, cumulative. Of adults presenting to the ED, 6.6% were hospitalized and discharged with a primary diagnosis of syncope (Cohort 1), 8.7% were hospitalized and discharged with a primary diagnosis other than syncope (Cohort 2), and 84.7% were discharged home with a syncope diagnosis (Cohort 3). The 30-day ED revisits for syncope varied from 1.2% (Cohort 2) to 2.4% (Cohort 1) (p < 0.001), and readmission rates were <1% among cohorts. Short- and long-term mortality rates were highest for Cohort 2 and lowest for Cohort 3 (30-day mortality: Cohort 1 of 1.2%, Cohort 2 of 5.2%, Cohort 3 of 0.4%; p < 0.001) (1-year mortality: Cohort 1 of 9.2%, Cohort 2 of 17.7%, Cohort 3 of 3.0%; p < 0.001). Total cost of syncope presentations was $530.6 million (Cohort 1: $75.3 million; $29,519/patient, Cohort 2: $138.1 million; $42,042/patient, Cohort 3: $317.3 million; $9,963/patient; p<0.001). Most patients with syncope presenting to the ED were discharged and had a favorable prognosis but overall costs were high compared with patients hospitalized. Further research is needed for cost-saving strategies across all cohorts. Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Sweat patterns differ between tilt-induced reflex syncope and tilt-induced anxiety among youth.

PubMed

Heyer, Geoffrey L; Harvey, Rebecca A; Islam, Monica P

2016-08-01

Profound sweating can occur with reflex-syncope and with emotional distress, but little is known about the similarities and differences between these sweat responses when they occur during orthostatic challenge. We sought to characterize and compare the sweat patterns related to tilt-induced syncope, presyncope, anxiety, and normal tilt testing. In a prospective observational study, quantitative sweat rate was measured from the abdomen, forearm, ankle, and thigh during head-upright tilt. Sweat characteristics were compared across tilt diagnoses of syncope, presyncope, anxiety, and normal testing. When anxiety and syncope/presyncope occurred during the same study (separated by ≥6 min), both were diagnosed. Our cohort comprised150 patients (15.1 ± 2.3 years; 82.9 % female) with 156 diagnoses: 76 with reflex-syncope, 31 with presyncope, 23 with anxiety, and 26 with normal results. All syncope/presyncope patients and 20 (87 %) of the anxiety patients had corresponding sweat responses. Minimal or negligible sweating occurred among patients with normal tests. Neither basal sweat (19.4 ± 4.7 versus 18.3 ± 3.7 versus 18.5 ± 3.7 nL/min/cm(2)) nor peak sweat (171 ± 47.4 versus 149.4 ± 64.4 versus 154.4 ± 59.2 nL/min/cm(2)) differed between patients with syncope, presyncope, or anxiety, p = .32 and p = .12, respectively. However, the qualitative sweat patterns related to syncope/presyncope (diffuse, smoothly contoured, symmetrical, single peaks) differed considerably from the sweat patterns related to anxiety (heterogeneous, asymmetrical, roughly contoured single-peak, multi-peak, or progressive sweat changes). The sweat patterns related to syncope/presyncope are distinguishable from the sweat patterns related to anxiety. Recognition of the different sweat patterns can inform how signs and symptoms are interpreted during clinical orthostatic challenge.

The use of adenosine and adenosine triphosphate testing in the diagnosis, risk stratification and management of patients with syncope: current evidence and future perspectives.

PubMed

Fragakis, Nikolaos; Antoniadis, Antonios P; Saviano, Massimo; Vassilikos, Vassilios; Pappone, Carlo

2015-03-15

Syncope is a significant source of cardiovascular-related morbidity yet the etiology is frequently obscure and the identification of patients at highest risk is challenging. Adenosine (AD) and adenosine triphosphate (ATP) administrations have been suggested as potentially useful non-invasive tools in the diagnostic workup of patients with neurally-mediated or bradycardia-related syncope. It has been postulated that both compounds by modulating the autonomic innervation in the heart and exerting negative chronotropic and dromotropic effects in the conduction system, may unmask the mechanism of syncope. However, the clinical implications derived from the efficacy of both tests in the investigation of syncope remain unclear mainly due to inconclusive and occasionally contradictory results of published studies. This review article summarizes recent and past information in the use of ATP and AD in the investigation of syncope with emphasis on clinical trials. We present the current level of evidence for the use of these agents in clinical practice, identify areas where further research is warranted and highlight the future perspectives of these agents as complements to an accurate risk-stratification of patients with syncope. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Syncope Best Practices: A Syncope Clinical Practice Guideline to Improve Quality.

PubMed

Phelps, Heather M; Sachdeva, Ritu; Mahle, William T; McCracken, Courtney E; Kelleman, Michael; McConnell, Michael; Fischbach, Peter S; Cardis, Brian M; Campbell, Robert M; Oster, Matthew E

2016-05-01

To determine whether implementation of a standardized clinical practice guideline (CPG) for the evaluation of syncope would decrease practice variability and resource utilization. A retrospective review of medical records of patients presenting to our practice for outpatient evaluation of syncope before and after implementation of the CPG. The guideline included elements of history, physical exam, electrocardiogram, and "red flags" for further testing. Outpatient pediatric cardiology offices of a large pediatric cardiology practice. All new patients between 3 and 21 years old, who presented to cardiology clinic with a chief complaint of syncope. The CPG for the evaluation of pediatric syncope was presented to the providers. Resource utilization was determined by the tests ordered by individual physicians before and after initiation of the CPG. Patient final diagnoses were recorded and the medical records were subsequently reviewed to determine if any patients, who presented again to the system, were ultimately diagnosed with cardiac disease. Of the 1496 patients with an initial visit for syncope, there was no significant difference in the diagnosis of cardiac disease before or after initiation of the CPG: (0.6% vs. 0.4%, P = .55). Electrocardiography provides the highest yield in the evaluation of pediatric syncope. Despite high compliance (86.9%), there were no overall changes in costs ($346.31 vs. $348.53, P = .85) or in resource utilization. There was, however, a decrease in the variability of ordering of echocardiograms among physicians, particularly among those at the extremes of utilization. Although the CPG did not decrease already low costs, it did decrease the wide variability in echo utilization. Evaluation beyond detailed history, physical exam, and electrocardiography provides no additional benefit in the evaluations of pediatric patients presenting with syncope. © 2015 Wiley Periodicals, Inc.

Summer syncope syndrome.

PubMed

Huang, Jennifer Juxiang; Sharda, Natasha; Riaz, Irbaz Bin; Alpert, Joseph S

2014-08-01

Antihypertensive therapy is associated with significant relative risk reductions in the incidence of heart failure, myocardial infarction, and stroke. However, a common adverse reaction to antihypertensive therapy is orthostatic hypotension, dehydration, and syncope. We propose that continued use of antihypertensive medications at the same dosage during the dry summer months in patients living in the Sonoran desert leads to an increase in syncopal episodes. All hypertensive patients who were treated with medications and admitted with International Classification of Diseases, 9th Revision code diagnosis of syncope were included. They were defined as "cases" if they presented during the summer months (May to September 2012) and "controls" if they presented during the winter months (November 2012 to March 2013). The primary outcome measure was the presence of clinical dehydration. The statistical significance was determined using the 2-sided Fisher exact test. A total of 496 patients with an International Classification of Diseases, 9th Revision code diagnosis of syncope were screened, and 179 patients were included in the final analysis. In patients taking antihypertensive medications, there were a significantly higher number of cases of syncope secondary to dehydration or orthostatic hypotension during the summer months (45%) compared with the winter months (26%) (P = .01). The incidence of syncope was significantly higher in older patients (63%) compared with younger individuals (37%) during the summer months. The incidence of syncope increases during the summer months among people who reside in a dry desert climate and who are taking antihypertensive medications. On the basis of our findings, we describe an easily preventable condition that we define as the "Summer Syncope Syndrome." We recommend judicious reduction of antihypertensive therapy in patients residing in a hot and dry climate, particularly during the summer months. Copyright © 2014 Elsevier Inc. All rights reserved.

The choice of surgical specialization by medical students and their syncopal history.

PubMed

Rudnicki, Jerzy; Zyśko, Dorota; Kozłowski, Dariusz; Kuliczkowski, Wiktor; Koźluk, Edward; Lelonek, Małgorzata; Piątkowska, Agnieszka; Gajek, Jacek; Negrusz-Kawecka, Marta; Agrawal, Anil Kumar

2013-01-01

The aim of the study was to assess whether medical students' fainting outside the university or while witnessing surgical procedures and/or autopsies influenced their choice of a specialization. The study group consisted of 605 medical students (from fourth to sixth year of study) from five medical universities in Poland (325 women, 212 men and 8 responders of an unspecified gender). The median age of subjects studied was 23 years, and the interquartile range was 23-24 years. The students at each university were chosen randomly by the author who worked there and had contact with them. An anonymous questionnaire was developed to gather information regarding demographics, the specialization which each student wanted to choose, the syncope occurrence in the medical history, the syncope and presyncope occurrence during surgery and autopsy as well as the syncopal events' characteristics. The group of 15% of women and 30% of men declared to have pursued the surgical specialization (P<0.001), 29% of women and 56% of men declared the intention to pursue an invasive specialization (P<0.001). As many as 36.0% of women studied and 13.1% of men studied reported syncopal spells outside university (P<0.001). Only 41 students (6.8%) reported that syncope or presyncope in any studied circumstances had an impact on their specialization choice. The multivariate analysis showed that the choice of surgical specialization is related to the male gender and the absence of syncopal spells outside the university. Syncopal and presyncopal spells may affect the professional choices of the medical students. The male gender and a lack of syncope occurrence outside operating room are related to the choice of surgical specialization.

The Choice of Surgical Specialization by Medical Students and Their Syncopal History

PubMed Central

Rudnicki, Jerzy; Zyśko, Dorota; Kozłowski, Dariusz; Kuliczkowski, Wiktor; Koźluk, Edward; Lelonek, Małgorzata; Piątkowska, Agnieszka; Gajek, Jacek; Negrusz-Kawecka, Marta; Agrawal, Anil Kumar

2013-01-01

Background The aim of the study was to assess whether medical students’ fainting outside the university or while witnessing surgical procedures and/or autopsies influenced their choice of a specialization. Materials and Methods The study group consisted of 605 medical students (from fourth to sixth year of study) from five medical universities in Poland (325 women, 212 men and 8 responders of an unspecified gender). The median age of subjects studied was 23 years, and the interquartile range was 23–24 years. The students at each university were chosen randomly by the author who worked there and had contact with them. An anonymous questionnaire was developed to gather information regarding demographics, the specialization which each student wanted to choose, the syncope occurrence in the medical history, the syncope and presyncope occurrence during surgery and autopsy as well as the syncopal events’ characteristics. Results The group of 15% of women and 30% of men declared to have pursued the surgical specialization (P<0.001), 29% of women and 56% of men declared the intention to pursue an invasive specialization (P<0.001). As many as 36.0% of women studied and 13.1% of men studied reported syncopal spells outside university (P<0.001). Only 41 students (6.8%) reported that syncope or presyncope in any studied circumstances had an impact on their specialization choice. The multivariate analysis showed that the choice of surgical specialization is related to the male gender and the absence of syncopal spells outside the university. Conclusions Syncopal and presyncopal spells may affect the professional choices of the medical students. The male gender and a lack of syncope occurrence outside operating room are related to the choice of surgical specialization. PMID:23383122

Cardiac pacing for severe childhood neurally mediated syncope with reflex anoxic seizures

PubMed Central

McLeod, K; Wilson, N; Hewitt, J; Norrie, J; Stephenson, J

1999-01-01

OBJECTIVE—To determine whether permanent cardiac pacing could prevent syncope and seizures in children with frequent severe neurally mediated syncope, and if so whether dual chamber pacing was superior to single chamber ventricular pacing.
METHODS—Dual chamber pacemakers were implanted into 12 children (eight male, four female) aged 2-14 years (median 2.8 years) with frequent episodes of reflex anoxic seizures and a recorded prolonged asystole during an attack. The pacemaker was programmed to sensing only (ODO), single chamber ventricular pacing with hysteresis (VVI), and dual chamber pacing with rate drop response (DDD) for four month periods, with each patient allocated to one of the six possible sequences of these modes, according to chronological order of pacemaker implantation. The parent and patient were blinded to the pacemaker mode and asked to record all episodes of syncope or presyncope ("near miss" events). The doctor analysing the results was blinded to the patient and pacemaker mode.
RESULTS—One patient was withdrawn from the study after the pacemaker was removed because of infection. In the remaining children, both dual chamber and single chamber pacing significantly reduced the number of syncopal episodes compared with sensing only (p = 0.0078 for both). VVI was as effective as DDD for preventing syncope, but DDD was superior to VVI in reducing near miss events (p = 0.016).
CONCLUSIONS—Permanent pacing is an effective treatment for children with severe neurally mediated syncope and reflex anoxic seizures. VVI is as effective as DDD in preventing syncope and seizures, but DDD is superior in preventing overall symptoms.


Keywords: syncope; reflex anoxic seizures; pacing; paediatric cardiology PMID:10573501

Obstetric outcomes of recurrent pregnancy loss patients diagnosed wıth inherited thrombophilia.

PubMed

Karadağ, C; Yoldemir, T; Karadağ, S D; İnan, C; Dolgun, Z N; Aslanova, L

2017-08-01

Recurrent pregnancy loss (RPL) is defined by two or more failed pregnancies. The relation between RPL and inherited thrombophilia requires anticoagulant therapy during pregnancy. However the obstetric outcomes have not been well defined in these RPL patients diagnosed with inherited thrombophilia, who have been given anticoagulant therapy. To investigate the obstetric outcomes in pregnant women with RPL who are given low molecular weight heparin (LMWH) and low-dose aspirin due to diagnosis of inherited thrombophilia. A hundred and eight RPL women were diagnosed with inherited thrombophilia, and 98 women were diagnosed with unexplained RPL. The patients with inherited thrombophilia were given LMWH and low-dose aspirin. Unexplained RPL patients were not given any medicine. The obstetric outcomes of participants were noted. In thrombophilic group, the live-birth levels were significantly higher [90 (83%) vs 67 (68%) p < 0.05], and the miscarriage levels were significantly lower than that in the control group [14 (13%) vs 27 (28%) p < 0.01]. The number of patients with preeclampsia was significantly higher in the thrombophilic group [16 (15%) vs 6 (6%) p < 0.05]. The number of preterm births was significantly higher than that of the controls [25 (23%) vs 10 (10%) p < 0.05]. The median gestation age of delivery was 35 weeks for thrombophilic patients and 38 weeks for controls (p < 0.05). The RPL patients diagnosed with inherited thrombophilia and who were given LMWH with low-dose aspirin had higher live-birth rates and lower miscarriage rates than those in the unexplained RPL patients. Increased risk of preeclampsia is seen in RPL patients with inherited thrombophilia despite thrombophilia prophylaxis.

Diagnostic Yield and Economic Assessment of a Diagnostic Protocol With Systematic Use of an External Loop Recorder for Patients With Palpitations.

PubMed

Francisco-Pascual, Jaume; Santos-Ortega, Alba; Roca-Luque, Ivo; Rivas-Gándara, Nuria; Pérez-Rodón, Jordi; Milà-Pascual, Laia; García-Dorado, David; Moya-Mitjans, Àngel

2018-05-24

To assess the diagnostic yield and cost-effectiveness of a diagnostic protocol based on the systematic use of latest-generation external loop recorders (ELRs) compared with the classic diagnostic strategy for patients with recurrent unexplained palpitations. Two cohorts of consecutive patients referred for diagnosis of unexplained palpitations to the outpatient clinic of the arrhythmia unit were compared: a prospective cohort after the implementation of a new diagnostic protocol based on the systematic use of ELRs, and another, retrospective, cohort before the implementation of the protocol. The cost of diagnosis was calculated based on the number of complementary examinations, visits to outpatient clinics, or emergency department visits required to reach a diagnosis, and its costs according the prices published for the local health system. One hundred and forty-nine patients were included (91 in the ELR group, 58 in the control group). The diagnostic yield was higher in the ELR group (79 [86.8%] definitive diagnoses in the ELR group vs 12 [20.7%] in the control group, P < .001). The cost per diagnosis was €375.13 in the ELR group and €5184.75 in the control group (P < .001). The cost-effectiveness study revealed that the systematic use of ELR resulted in a cost reduction of €11.30 for each percentage point of increase in diagnosis yield. In patients with recurrent unexplained palpitations, evaluation by means of a study protocol that considers the systematic use of a latest-generation ELR increases diagnostic yield while reducing the cost per diagnosis. Copyright © 2018 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

A study on phthalate metabolites, bisphenol A and nonylphenol in the urine of Chinese women with unexplained recurrent spontaneous abortion.

PubMed

Peng, Fanli; Ji, Wenliang; Zhu, Feng; Peng, Danhong; Yang, Miao; Liu, Ran; Pu, Yuepu; Yin, Lihong

2016-10-01

Humans are widely exposed to phthalates, bisphenol A and nonylphenol owing to the ubiquitous use of these chemicals in consumer products. Increasing attention has been paid to exposure to phthalates, bisphenol A and nonylphenol because of their potential adverse effects on human fertility. A validated method was developed to investigate the three classes of environmental estrogen, mentioned above, in the urine of Chinese women of Nanjing area with unexplained recurrent spontaneous abortion. Solid-phase extraction coupled with ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) was used. In this method, amounts of bisphenol A (BPA), nonylphenol (NP) and four phthalate metabolites, mono-n-butyl phthalate (MBP), mono-isobutyl phthalate (MiBP), mono-benzyl phthalate (MBzP) and mono-2-ethylhexyl phthalate (MEHP), along with their isotope labeled internal standards, were measured using UPLC-MS/MS operated in negative electrospray ionization multiple reaction monitoring mode. The limits of detection were 0.3ng/mL for the four phthalate metabolites, and 0.5ng/mL for bisphenol A and nonylphenol. For women with unexplained recurrent spontaneous abortion, the mean concentrations of MBP, MiBP, MBzP, MEHP, BPA and 4-n-NP were 6.52±6.04, 5.51±4.19, 0.53±0.42, 10.12±4.16, 7.13±7.42, 0.41±0.49ng/mL (mean±SD), respectively. For the control group, the mean concentrations of the corresponding analytes were 4.15±3.57, 2.96±3.30, 0.46±0.49, 6.50±2.81, 4.43±2.23,0.48±0.43ng/mL (mean±SD), respectively. Levels of MiBP and MEHP were significantly different between the two groups, using Wilcoxon rank sum tests. This method can be applied in epidemiological studies to explore the association between exposure to environmental estrogens and relevant adverse outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

Journal Club: Head CT scans in the emergency department for syncope and dizziness.

PubMed

Mitsunaga, Myles M; Yoon, Hyo-Chun

2015-01-01

The purpose of this study was to determine the yield of acutely abnormal findings on head CT scans in patients presenting to the emergency department with dizziness, near-syncope, or syncope and to determine the clinical factors that potentially predicted acutely abnormal head CT findings and hospital admission. We retrospectively reviewed the electronic medical records of all patients presenting to an HMO emergency department between July 1, 2012, and December 31, 2012, who underwent head CT for a primary complaint of dizziness, syncope, or near-syncope. The primary outcomes were head CT scans with acutely abnormal findings and hospital admission. Binary logistic regression was used to assess the association between clinical variables and acute head CT findings and between clinical variables and hospital admission. Of the 253 patients who presented with dizziness, 7.1% had head CT scans with acutely abnormal findings, and 18.6% were admitted. Of the 236 patients who presented with syncope or near-syncope, 6.4% had head CT scans with acutely abnormal findings, and 39.8% were admitted. The following three clinical factors were found to be significantly correlated with acutely abnormal head CT findings: a focal neurologic deficit (p = 0.003), age greater than 60 years (p = 0.011), and acute head trauma (p = 0.026). Our results suggest that most patients presenting with syncope or dizziness to the emergency department may not benefit from head CT unless they are older, have a focal neurologic deficit, or have a history of recent head trauma.

Pulmonary embolism presenting with itinerant chest pain and migratory pleural effusion: A case report.

PubMed

Li, Wei; Chen, Chen; Chen, Mo; Xin, Tong; Gao, Peng

2018-06-01

Pulmonary embolism (PE) presents with complex clinical manifestations ranging from asymptomatic to chest pain, hemoptysis, syncope, shock, or sudden death. To the authors' knowledge, itinerant chest pain has not been reported as sign or symptom of PE. A 41-year-old woman presenting with left chest pain, no hemoptysis, or breathing difficulties. The chest pain was more severe on deep inspiration. Chest computed tomography (CT) and ultrasound imaging showed left pleural effusion. After antibiotic treatment, the left chest pain was alleviated, but a similar pain appeared in the right chest. Electrocardiogram, blood gas analysis, echocardiography, and D-dimer levels were unremarkable. Chest CT showed right pleural effusion. A CT pulmonary angiography (CTPA) unexpectedly revealed a PE in the right pulmonary artery. The patient was administered anticoagulant therapy and made a complete recovery. The use of CTPA to investigate the possible presence of PE in patients with unexplained migratory pleural effusion complaining of itinerant chest pain is important. Lessons should be learned from the early use of CTPA to investigate the possible presence of PE in patients.

The Cost-Effective Evaluation of Syncope.

PubMed

Angus, Steven

2016-09-01

Syncope is a common clinical problem that carries a high socioeconomic burden. A structured approach in the evaluation of syncope with special emphasis on a detailed history, comprehensive physical examination that includes orthostatic vital signs, and an electrocardiogram, proves to be the most cost-effective approach. The need for additional testing and hospital admission should be based on the results of the initial evaluation and use of risk-stratification tools that help identify those syncope patients at highest risk for poor outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

Syncope in the young athlete: Assessment of prognosis in subjects with hypertrophic cardiomyopathy.

PubMed

Magalhães-Ribeiro, Carlos; Freitas, João

2016-01-01

Syncope is a common but concerning event in young athletes. Although mostly due to benign reflex causes, syncope may be arrhythmic and precede sudden cardiac death. Efforts must therefore be made to distinguish post-exertional syncope from syncope during exercise, which can be an ominous sign of a possible underlying heart disease, such as hypertrophic cardiomyopathy. Prevention requires cooperation between physician and athlete, in order to identify individuals at risk and to protect them from sudden death. Solving this diagnostic dilemma may lead to recommendations for athletes to be cleared to play or disqualified from competitive sports, and presents challenging and controversial decisions to the health care provider that can prove difficult to implement. Although exercise contributes to physical and psychological well-being, there are insufficient data to indicate whether an athlete with hypertrophic cardiomyopathy diagnosed after a syncopal episode can safely resume competitive physical activity. The purpose of this study was to review the literature on syncope in young athletes and its relationship to individuals with hypertrophic cardiomyopathy, in order to enable accurate assessment of prognosis and the possibility of resuming competitive sports. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Long QT molecular autopsy in sudden unexplained death in the young (1-40 years old): Lessons learnt from an eight year experience in New Zealand.

PubMed

Marcondes, Luciana; Crawford, Jackie; Earle, Nikki; Smith, Warren; Hayes, Ian; Morrow, Paul; Donoghue, Tom; Graham, Amanda; Love, Donald; Skinner, Jonathan R

2018-01-01

To review long QT syndrome molecular autopsy results in sudden unexplained death in young (SUDY) between 2006 and 2013 in New Zealand. Audit of the LQTS molecular autopsy results, cardiac investigations and family screening data from gene-positive families. During the study period, 365 SUDY cases were referred for molecular autopsy. 128 cases (35%) underwent LQTS genetic testing. 31 likely pathogenic variants were identified in 27 cases (21%); SCN5A (14/31, 45%), KCNH2 (7/31, 22%), KCNQ1 (4/31, 13%), KCNE2 (3/31, 10%), KCNE1 (2/31, 7%), KCNJ2 (1/31, 3%). Thirteen variants (13/128, 10%) were ultimately classified as pathogenic. Most deaths (63%) occurred during sleep. Gene variant carriage was more likely with a positive medical history (mostly seizures, 63% vs 36%, p = 0.01), amongst females (36% vs 12%, p = 0.001) and whites more than Maori (31% vs 0, p = 0.0009). Children 1-12 years were more likely to be gene-positive (33% vs 14%, p = 0.02). Family screening identified 42 gene-positive relatives, 18 with definitive phenotypic expression of LQTS/Brugada. 76% of the variants were maternally inherited (p = 0.007). Further family investigations and research now support pathogenicity of the variant in 13/27 (48%) of gene-positive cases. In New Zealand, variants in SCN5A and KCNH2, with maternal inheritance, predominate. A rare variant in LQTS genes is more likely in whites rather than Maori, females, children 1-12 years and those with a positive personal and family history of seizures, syncope or SUDY. Family screening supported the diagnosis in a third of the cases. The changing classification of variants creates a significant challenge.

Summer syncope syndrome redux.

PubMed

Huang, Jennifer Juxiang; Desai, Chirag; Singh, Nirmal; Sharda, Natasha; Fernandes, Aaron; Riaz, Irbaz Bin; Alpert, Joseph S

2015-10-01

While antihypertensive therapy is known to reduce the risk for heart failure, myocardial infarction, and stroke, it can often cause orthostatic hypotension and syncope, especially in the setting of polypharmacy and possibly, a hot and dry climate. The objective of the present study was to investigate whether the results of our prior study involving continued use of antihypertensive drugs at the same dosage in the summer as in the winter months for patients living in the Sonoran desert resulted in an increase in syncopal episodes during the hot summer months. All hypertensive patients who were treated with medications and admitted with International Classification of Diseases, 9th Revision code diagnosis of syncope were included. This is a 3-year retrospective chart review study. They were defined as "cases" if they presented during the summer months (May to September) and "controls" if they presented during the winter months (November to March). The primary outcome measure was the presence of clinical dehydration. The statistical significance was determined using the 2-sided Fisher's exact test. A total of 834 patients with an International Classification of Diseases, 9th Revision code diagnosis of syncope were screened: 477 in the summer months and 357 in the winter months. In patients taking antihypertensive medications, there was a significantly higher number of cases of syncope secondary to dehydration during the summer months (40.5%) compared with the winter months (29%) (P = .04). No difference was observed in the type of antihypertensive medication used and syncope rate. The number of antihypertensives used did not increase the cases of syncope in either summer or winter. An increased number of syncope events was observed in the summer months among people who reside in a dry desert climate and who are taking antihypertensive medications. The data confirm our earlier observations that demonstrated a greater number of cases of syncope among people who reside in a dry desert climate who were taking antihypertensive medications during summer months. We recommend judicious reduction of antihypertensive therapy in patients residing in a hot and dry climate, particularly during the summer months. Copyright © 2015 Elsevier Inc. All rights reserved.

Blood pressure regulation X: what happens when the muscle pump is lost? Post-exercise hypotension and syncope.

PubMed

Halliwill, John R; Sieck, Dylan C; Romero, Steven A; Buck, Tahisha M; Ely, Matthew R

2014-03-01

Syncope which occurs suddenly in the setting of recovery from exercise, known as post-exercise syncope, represents a failure of integrative physiology during recovery from exercise. We estimate that between 50 and 80% of healthy individuals will develop pre-syncopal signs and symptoms if subjected to a 15-min head-up tilt following exercise. Post-exercise syncope is most often neurally mediated syncope during recovery from exercise, with a combination of factors associated with post-exercise hypotension and loss of the muscle pump contributing to the onset of the event. One can consider the initiating reduction in blood pressure as the tip of the proverbial iceberg. What is needed is a clear model of what lies under the surface; a model that puts the observational variations in context and provides a rational framework for developing strategic physical or pharmacological countermeasures to ultimately protect cerebral perfusion and avert loss of consciousness. This review summarizes the current mechanistic understanding of post-exercise syncope and attempts to categorize the variation of the physiological processes that arise in multiple exercise settings. Newer investigations into the basic integrative physiology of recovery from exercise provide insight into the mechanisms and potential interventions that could be developed as countermeasures against post-exercise syncope. While physical counter maneuvers designed to engage the muscle pump and augment venous return are often found to be beneficial in preventing a significant drop in blood pressure after exercise, countermeasures that target the respiratory pump and pharmacological countermeasures based on the involvement of histamine receptors show promise.

Blood pressure regulation X: What happens when the muscle pump is lost? Post-exercise hypotension and syncope

PubMed Central

Halliwill, John R.; Sieck, Dylan C.; Romero, Steven A.; Buck, Tahisha M.; Ely, Matthew R.

2013-01-01

Syncope which occurs suddenly in the setting of recovery from exercise, known as post-exercise syncope, represents a failure of integrative physiology during recovery from exercise. We estimate that between 50 and 80% of healthy individuals will develop pre-syncopal signs and symptoms if subjected to a 15-min head-up tilt following exercise. Post-exercise syncope is most often neurally mediated syncope during recovery from exercise, with a combination of factors associated with post-exercise hypotension and loss of the muscle pump contributing to the onset of the event. One can consider the initiating reduction in blood pressure as the tip of the proverbial iceberg. What is needed is a clear model of what lies under the surface; a model that puts the observational variations in context and provides a rational framework for developing strategic physical or pharmacological countermeasures to ultimately protect cerebral perfusion and avert loss of consciousness. This review summarizes the current mechanistic understanding of post-exercise syncope and attempts to categorize the variation of the physiological processes that arise in multiple exercise settings. Newer investigations into the basic integrative physiology of recovery from exercise provide insight into the mechanisms and potential interventions that could be developed as countermeasures against post-exercise syncope. While physical counter maneuvers designed to engage the muscle pump and augment venous return are often found to be beneficial in preventing a significant drop in blood pressure after exercise, countermeasures that target the respiratory pump and pharmacological countermeasures based on the involvement of histamine receptors show promise. PMID:24197081

Regional Implementation of a Pediatric Cardiology Syncope Algorithm Using Standardized Clinical Assessment and Management Plans (SCAMPS) Methodology.

PubMed

Paris, Yvonne; Toro-Salazar, Olga H; Gauthier, Naomi S; Rotondo, Kathleen M; Arnold, Lucy; Hamershock, Rose; Saudek, David E; Fulton, David R; Renaud, Ashley; Alexander, Mark E

2016-02-19

Pediatric syncope is common. Cardiac causes are rarely found. We describe and assess a pragmatic approach to these patients first seen by a pediatric cardiologist in the New England region, using Standardized Clinical Assessment and Management Plans (SCAMPs). Ambulatory patients aged 7 to 21 years initially seen for syncope at participating New England Congenital Cardiology Association practices over a 2.5-year period were evaluated using a SCAMP. Findings were iteratively analyzed and the care pathway was revised. The vast majority (85%) of the 1254 patients had typical syncope. A minority had exercise-related or more problematic symptoms. Guideline-defined testing identified one patient with cardiac syncope. Syncope Severity Scores correlated well between physician and patient perceived symptoms. Orthostatic vital signs were of limited use. Largely incidental findings were seen in 10% of ECGs and 11% of echocardiograms. The 10% returning for follow-up, by design, reported more significant symptoms, but did not have newly recognized cardiac disease. Iterative analysis helped refine the approach. SCAMP methodology confirmed that the vast majority of children referred to the outpatient pediatric cardiology setting had typical low-severity neurally mediated syncope that could be effectively evaluated in a single visit using minimal resources. A simple scoring system can help triage patients into treatment categories. Prespecified criteria permitted the effective diagnosis of the single patient with a clear cardiac etiology. Patients with higher syncope scores still have a very low risk of cardiac disease, but may warrant attention. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Alterations of brain network hubs in reflex syncope: Evidence from a graph theoretical analysis based on DTI.

PubMed

Park, Bong Soo; Lee, Yoo Jin; Park, Jin-Han; Kim, Il Hwan; Park, Si Hyung; Lee, Ho-Joon; Park, Kang Min

2018-06-01

We evaluated global topology and organization of regional hubs in the brain networks and microstructural abnormalities in the white matter of patients with reflex syncope. Twenty patients with reflex syncope and thirty healthy subjects were recruited, and they underwent diffusion tensor imaging (DTI) scans. Graph theory was applied to obtain network measures based on extracted DTI data, using DSI Studio. We then investigated differences in the network measures between the patients with reflex syncope and the healthy subjects. We also analyzed microstructural abnormalities of white matter using tract-based spatial statistics analysis (TBSS). Measures of global topology were not different between patients with reflex syncope and healthy subjects. However, in reflex syncope patients, the strength measures of the right angular, left inferior frontal, left middle orbitofrontal, left superior medial frontal, and left middle temporal gyrus were lower than in healthy subjects. The betweenness centrality measures of the left middle orbitofrontal, left fusiform, and left lingual gyrus in patients were lower than those in healthy subjects. The PageRank centrality measures of the right angular, left middle orbitofrontal, and left superior medial frontal gyrus in patients were lower than those in healthy subjects. Regarding the analysis of the white matter microstructure, there were no differences in the fractional anisotropy and mean diffusivity values between the two groups. We have identified a reorganization of network hubs in the brain network of patients with reflex syncope. These alterations in brain network may play a role in the pathophysiologic mechanism underlying reflex syncope. © 2018 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.

[Study on the relationship of MTHFR polymorphisms with unexplained recurrent spontaneous abortion].

PubMed

Li, Xiao-mei; Zhang, You-zhong; Xu, Yan-xue; Jiang, Sen

2004-02-01

To assess the relationship of methylenetetrahydrofolate reductase (MTHFR) C677T genotypes to unexplained recurrent spontaneous abortion (URSA). This study included two groups:57 currently non-pregnant women with a history of URSA (URSA group), and 50 currently non-pregnant women with a history of having given birth to at least one live baby and without any history of spontaneous abortion, still-born fetus, placental thrombosis and intrauterine growth retardation(IUGR)(control group). The fasting serum-Hcy was measured with high pressure liquid chromatography. Folic acid and vitamin B(12) were detected by radioimmune assay; antiphospholipid antibody (ACA) was detected by ELISA. MTHFR C677T gene polymorphisms were detected by the technique of polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). C/C genotype in URSA group was significantly lower than that in control group, the total mutant T allele frequency was significantly higher than that in control group. There was no significant difference in respect of "age, rural area/city, period, primary/secondary abortion" between the genotype distributions of MTHFR C677T. The T/T genotype and C/T+T/T genotypes frequencies for "abortion times>or=3" were higher than those for "abortion time <3". MTHFR C677T gene polymorphism is a genetic risk factor for URSA.

Serum cardiac troponin I in canine syncope and seizures.

PubMed

Dutton, E; Dukes-McEwan, J; Cripps, P J

2017-02-01

To determine if serum cardiac troponin I (cTnI) concentration distinguishes between cardiogenic syncope and collapsing dogs presenting with either generalized epileptic seizures (both with and without cardiac disease) or vasovagal syncope. Seventy-nine prospectively recruited dogs, grouped according to aetiology of collapse: generalized epileptic seizures (group E), cardiogenic syncope (group C), dogs with both epileptic seizures and cardiac disease (group B), vasovagal syncope (group V) or unclassified (group U). Most patients had ECG (n = 78), echocardiography (n = 78) and BP measurement (n = 74) performed. Dogs with a history of intoxications, trauma, evidence of metabolic disorders or renal insufficiency (based on serum creatinine concentrations >150 μmol/L and urine specific gravity <1.030) were excluded. Serum cTnI concentrations were measured and compared between groups using non-parametric statistical methods. Multivariable regression analysis investigated factors associated with cTnI. Receiver operator characteristic curve analysis examined whether cTnI could identify cardiogenic syncope. Median cTnI concentrations were higher in group C than E (cTnI: 0.165 [0.02-27.41] vs. 0.03 [0.01-1.92] ng/mL; p<0.05). Regression analysis found that serum cTnI concentrations decreased with increasing time from collapse (p=0.015) and increased with increasing creatinine concentration (p=0.028). Serum cTnI diagnosed cardiogenic syncope with a sensitivity of 75% and specificity of 80%. Serum cTnI concentrations were significantly different between groups C and E. However, due to the overlap in cTnI concentrations between groups cTnI, measurement in an individual is not optimally discriminatory to differentiate cardiogenic syncope from collapse with generalized epileptic seizures (both with and without cardiac disease) or vasovagal syncope. Copyright © 2016 Elsevier B.V. All rights reserved.

Pregnancy failure and heritable thrombophilia.

PubMed

Middeldorp, Saskia

2007-04-01

Heritable thrombophilia is associated with an increased risk for pregnancy failure, defined as sporadic and recurrent miscarriage, late fetal loss, and other vascular pregnancy complications such as preeclampsia and intrauterine growth retardation. The pathogenesis is likely to include effects on trophoblast differentiation and not solely hypercoagulability. This is in line with the observation that most recurrent miscarriages occur early. Therapeutic options include aspirin as well as low-molecular-weight heparin. However, in women with heritable thrombophilia and unexplained recurrent pregnancy loss, evidence is not available as published trials have not used an adequate comparator (no treatment or placebo). Currently, randomized controlled trials with no treatment or placebo are being carried out and results should be awaited before implementing a potentially harmful intervention in pregnant women with heritable thrombophilia and a history of pregnancy failure. Both infertility and pregnancy failure are extremely distressing for couples with the desire to have children. Pregnancy failure comprises (recurrent) early miscarriage, as well as late pregnancy loss. The role of heritable thrombophilia in pregnancy failure is reviewed, with a focus on recurrent miscarriage, in terms of epidemiology, etiology, and potential therapeutic implications.

The diagnostic value of EEGs in patients with syncope.

PubMed

Abubakr, Abuhuziefa; Wambacq, Ilse

2005-05-01

We retrospectively reviewed reports of all EEGs performed at the New Jersey Neuroscience Institute at JFK Hospital between January 1999 and December 2003. Of 9234 EEGs performed, 1094 were of patients with syncope. Among patients with syncope, 67.18% of the EEGs were normal and 28.15% showed diffuse and focal slowing. Only 1.46% of the EEGs showed epileptiform discharges (EDs). This is similar to the incidence of EDs in healthy adults. The presence of EDs did not change the management of these patients. Therefore, EEGs have very low yield and should not be routinely obtained in patients with syncope.

Self-induced stretch syncope of adolescence: a video-EEG documentation.

PubMed

Mazzuca, Michel; Thomas, Pierre

2007-12-01

We present the first video-EEG documentation, with ECG and EMG features, of stretch syncope of adolescence in a young, healthy 16-year-old boy. Stretch syncope of adolescence is a rarely reported, benign cause of fainting in young patients, which can be confused with epileptic seizures. In our patient, syncopes were self-induced to avoid school. Dynamic transcranial Doppler showed evidence of blood flow decrease in both posterior cerebral arteries mimicking effects of a Valsalva manoeuvre. Dynamic angiogram of the vertebral arteries was normal. Hypotheses concerning the physiopathology are discussed. [Published with video sequences].

Validation of EGSYS Score in Prediction of Cardiogenic Syncope

PubMed Central

Kariman, Hamid; Harati, Sepideh; Safari, Saeed; Baratloo, Alireza; Pishgahi, Mehdi

2015-01-01

Introduction. Evaluation of Guidelines in Syncope Study (EGSYS) is designed to differentiate between cardiac and noncardiac causes of syncope. The present study aimed to evaluate the accuracy of this predictive model. Methods. In this prospective cross-sectional study, screening performance characteristics of EGSYS-U (univariate) and EGSYS-M (multivariate) in prediction of cardiac syncope were calculated for syncope patients who were referred to the emergency department (ED). Results. 198 patients with mean age of 59.26 ± 19.5 years were evaluated (62.3% male). 115 (58.4%) patients were diagnosed with cardiac syncope. Area under the ROC curve was 0.818 (95% CI: 0.75–0.87) for EGSYS-U and 0.805 (CI 95%: 0.74–0.86) for EGSYS-M (p = 0.53). Best cut-off point for both models was ≥3. Sensitivity and specificity were 86.08% (95% CI: 78.09–91.59) and 68.29% (95% CI: 56.97–77.86) for EGSYS-U and 91.30% (95% CI: 84.20–95.52) and 57.32% (95% CI: 45.92–68.02) for EGSYS-M, respectively. Conclusion. The results of this study demonstrated the acceptable accuracy of EGSYS score in predicting cardiogenic causes of syncope at the ≥3 cut-off point. It seems that using this model in daily practice can help physicians select at risk patients and properly triage them. PMID:26649200

Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope.

PubMed

Thiruganasambandamoorthy, Venkatesh; Kwong, Kenneth; Wells, George A; Sivilotti, Marco L A; Mukarram, Muhammad; Rowe, Brian H; Lang, Eddy; Perry, Jeffrey J; Sheldon, Robert; Stiell, Ian G; Taljaard, Monica

2016-09-06

Syncope can be caused by serious conditions not evident during initial evaluation, which can lead to serious adverse events, including death, after disposition from the emergency department. We sought to develop a clinical decision tool to identify adult patients with syncope who are at risk of a serious adverse event within 30 days after disposition from the emergency department. We prospectively enrolled adults (age ≥ 16 yr) with syncope who presented within 24 hours after the event to 1 of 6 large emergency departments from Sept. 29, 2010, to Feb. 27, 2014. We collected standardized variables at index presentation from clinical evaluation and investigations. Adjudicated serious adverse events included death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, serious hemorrhage and procedural interventions within 30 days. We enrolled 4030 patients with syncope; the mean age was 53.6 years, 55.5% were women, and 9.5% were admitted to hospital. Serious adverse events occurred in 147 (3.6%) of the patients within 30 days after disposition from the emergency department. Of 43 candidate predictors examined, we included 9 in the final model: predisposition to vasovagal syncope, heart disease, any systolic pressure reading in the emergency department < 90 or > 180 mm Hg, troponin level above 99th percentile for the normal population, abnormal QRS axis (< -30° or > 100°), QRS duration longer than 130 ms, QTc interval longer than 480 ms, emergency department diagnosis of cardiac syncope and emergency department diagnosis of vasovagal syncope (C statistic 0.88, 95% confidence interval [CI] 0.85-0.90; optimism 0.015; goodness-of-fit p = 0.11). The risk of a serious adverse event within 30 days ranged from 0.4% for a score of -3 to 83.6% for a score of 11. The sensitivity was 99.2% (95% CI 95.9%-100%) for a threshold score of -2 or higher and 97.7% (95% CI 93.5%-99.5%) for a threshold score of -1 or higher. The Canadian Syncope Risk Score showed good discrimination and calibration for 30-day risk of serious adverse events after disposition from the emergency department. Once validated, the tool will be able to accurately stratify the risk of serious adverse events among patients presenting with syncope, including those at low risk who can be discharged home quickly. © 2016 Canadian Medical Association or its licensors.

Measuring quality of care in syncope: case definition affects reported electrocardiogram use but does not bias reporting.

PubMed

Schuur, Jeremiah D; Justice, Amy

2009-01-01

The objective was to calculate agreement between syncope as a reason for visiting (RFV) an emergency department (ED) and as a discharge diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9]), to determine whether syncope case definition biases reported electrocardiogram (ECG) usage, a national quality measure. The authors analyzed the ED portion of the National Hospital Ambulatory Medical Care Survey (NHAMCS), 1993-2004, for patients age >or=18 years. A visit was defined as being for syncope if it received one of three RFV or ICD-9 codes. Agreement between RFV and ICD-9 codes was calculated, and the percentages of syncope patients (RFV vs. ICD-9) who had an ECG were compared using chi-square and multivariate logistic regression. Raw agreement between syncope as an RFV and as an ICD-9 diagnosis code was 30.1% (95% confidence interval [CI] = 32.6% to 35.5%), representing only moderate agreement beyond chance (kappa = 0.50). ECG utilization was lower among visits defined by RFV (64.1%; 95% CI = 62.0% to 66.3%) than for ICD-9 diagnosis (73.6%; 95% CI = 71.4% to 75.8%). There was no meaningful variation in adjusted ECG use by patient, visit, or hospital characteristics between case definitions. Adjusted ECG use was lower under both case definitions among female patients and discharged patients and increased with age (p < 0.05). Despite only moderate agreement, syncope case definition should not bias reported ECG rate by patient, visit, or hospital characteristics. Among ED patients with syncope, ECG is performed less frequently in women, a potentially important disparity.

Dementia Medications and Risk of Falls, Syncope, and Related Adverse Events Meta-Analysis of Randomized Controlled Trials

PubMed Central

Kim, Dae Hyun; Brown, Rebecca T.; Ding, Eric L.; Kiel, Douglas P.; Berry, Sarah D.

2012-01-01

Background Conflicting evidence exists on whether cholinesterase inhibitors and memantine increase the risk of falls, syncope, and related events, defined as fracture and accidental injury. Objectives To evaluate the effect of cholinesterase inhibitors and memantine on the risk of falls, syncope, and related events Design, Setting, Participants, and Intervention Meta-analysis of 54 placebo-controlled randomized trials and extension studies of cholinesterase inhibitors and memantine that reported falls, syncope, and related events in cognitively impaired older adults. Trials were identified from MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (no language restriction, through July 2009), and manual search. Measurements Falls, syncope, fracture, and accidental injury Results Compared to placebo, cholinesterase inhibitor use was associated with an increased risk of syncope (odds ratio [95% confidence interval]: 1.53 [1.02-2.30]), but not with other events (falls: 0.88 [0.74-1.04]; fracture: 1.39 [0.75-2.56]; accidental injury: 1.13 [0.87-1.45]). Memantine use was associated with fewer fractures (0.21 [0.05-0.85]), but not with other events (fall: 0.92 [0.72-1.18]; syncope: 1.04 [0.35-3.04]; accidental injury: 0.80 [0.56-1.12]). There was no differential effect by type and severity of cognitive impairment, residential status, nor length of follow-up. However, due to underreporting and small number of events, a potential benefit or risk cannot be excluded. Conclusion Cholinesterase inhibitors may increase the risk of syncope, with no effects on falls, fracture, and accidental injury in cognitively impaired older adults. Memantine may have a favorable effect on fracture, with no effects on other events. More research is needed to confirm the reduction in fractures observed for memantine. PMID:21649634

Predictors of Hospitalization in Patients with Syncope Assisted in Specialized Cardiology Hospital

PubMed Central

Fischer, Leonardo Marques; Dutra, João Pedro Passos; Mantovani, Augusto; de Lima, Gustavo Glotz; Leiria, Tiago Luiz Luz

2013-01-01

Background Risk stratification of a syncopal episode is necessary to better differentiate patients needing hospitalization of those who can be safely sent home from the emergency department. Currently there are no strict guidelines from our Brazilian medical societies to guide the cardiologist that evaluate patients in an emergency setting. Objectives To analyze the criteria adopted for defining the need for hospitalization and compare them with the predictors of high risk for adverse outcome defined by the OESIL score that is already validated in the medical literature for assessing syncope. Methods A cross-sectional study of patients diagnosed with syncope during emergency department evaluation at our institution in the year 2011. Results Of the 46,476 emergency visits made in that year, 216 were due to syncope. Of the 216 patients analyzed, 39% were hospitalized. The variables associated with the need of hospital admission were - having health care insurance, previous known cardiovascular disease, no history of prior stroke, previous syncope and abnormal electrocardiograms during the presentation. Patients classified in OESIL scores of 0-1 had a greater chance of emergency discharge; 2-3 scores showed greater association with the need of hospitalization. A score ≥ 2 OESIL provided an odds ratio 7.8 times higher for hospitalization compared to score 0 (p <0.001, 95% CI:4,03-15,11). In approximately 39% no etiological cause for syncope was found and in 18% cardiac cause was identified. Conclusions Factors such as cardiovascular disease, prior history of syncope, health insurance, no previous stroke and abnormal electrocardiograms, were the criteria used by doctors to indicate hospital admission. There was a good correlation between the clinical judgment and the OESIL criteria for high risk described in literature. PMID:24145390

[Therapeutic approach to patients with neurocardiogenic syncope].

PubMed

Zyśko, Dorota; Gajek, Jacek; Halawa, Bogumił

2004-11-01

Vasovagal syncopes are the most common cause of loss of consciousness and if they occur frequently they contribute to the marked decrease of the quality of life and need treatment. One of important problems is the possibility of injury during the syncope. In older patients it can lead to the fractures of extremities, complications of which could be life-threatening. Another problem is the reaction of the surrounding people trying to help the unconscious by keeping him in the vertical position. It promotes hypotonia and could cause damage of organs such as brain or heart. The authors review the current literature on the management of patients with vasovagal syncope. It seems that the conservative approaches preferring patient reassurance and training methods are successful in syncope prevention and help avoid the side effects and complications of pharmacological therapy or pacemaker implantation. These last two methods should be reserved for patients with the most severe symptoms of the disease.

Syncope: risk stratification and clinical decision making.

PubMed

Peeters, Suzanne Y G; Hoek, Amber E; Mollink, Susan M; Huff, J Stephen

2014-04-01

Syncope is a common occurrence in the emergency department, accounting for approximately 1% to 3% of presentations. Syncope is best defined as a brief loss of consciousness and postural tone followed by spontaneous and complete recovery. The spectrum of etiologies ranges from benign to life threatening, and a structured approach to evaluating these patients is key to providing care that is thorough, yet cost-effective. This issue reviews the most relevant evidence for managing and risk stratifying the syncope patient, beginning with a focused history, physical examination, electrocardiogram, and tailored diagnostic testing. Several risk stratification decision rules are compared for performance in various scenarios, including how age and associated comorbidities may predict short-term and long-term adverse events. An algorithm for structured, evidence-based care of the syncope patient is included to ensure that patients requiring hospitalization are managed appropriately and those with benign causes are discharged safely.

Noninvasive beat-to-beat finger arterial pressure monitoring during orthostasis: a comprehensive review of normal and abnormal responses at different ages.

PubMed

van Wijnen, V K; Finucane, C; Harms, M P M; Nolan, H; Freeman, R L; Westerhof, B E; Kenny, R A; Ter Maaten, J C; Wieling, W

2017-12-01

Over the past 30 years, noninvasive beat-to-beat blood pressure (BP) monitoring has provided great insight into cardiovascular autonomic regulation during standing. Although traditional sphygmomanometric measurement of BP may be sufficient for detection of sustained orthostatic hypotension, it fails to capture the complexity of the underlying dynamic BP and heart rate responses. With the emerging use of noninvasive beat-to-beat BP monitoring for the assessment of orthostatic BP control in clinical and population studies, various definitions for abnormal orthostatic BP patterns have been used. Here, age-related changes in cardiovascular control in healthy subjects will be reviewed to define the spectrum of the most important abnormal orthostatic BP patterns within the first 180 s of standing. Abnormal orthostatic BP responses can be defined as initial orthostatic hypotension (a transient systolic BP fall of >40 mmHg within 15 s of standing), delayed BP recovery (an inability of systolic BP to recover to a value of >20 mmHg below baseline at 30 s after standing) and sustained orthostatic hypotension (a sustained decline in systolic BP of ≥20 mmHg occurring 60-180 s after standing). In the evaluation of patients with light-headedness, pre(syncope), (unexplained) falls or suspected autonomic dysfunction, it is essential to distinguish between normal cardiovascular autonomic regulation and these abnormal orthostatic BP responses. The prevalence, clinical relevance and underlying pathophysiological mechanisms of these patterns differ significantly across the lifespan. Initial orthostatic hypotension is important for identifying causes of syncope in younger adults, whereas delayed BP recovery and sustained orthostatic hypotension are essential for evaluating the risk of falls in older adults. © 2017 The Authors Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.

Cardiac Iodine-123-Meta-Iodo-Benzylguanidine Uptake in Carotid Sinus Hypersensitivity

PubMed Central

Tan, Maw Pin; Murray, Alan; Hawkins, Terry; Chadwick, Thomas J.; Kerr, Simon R. J.; Parry, Steve W.

2015-01-01

Background Carotid sinus syndrome is the association of carotid sinus hypersensitivity with syncope, unexplained falls and drop attacks in generally older people. We evaluated cardiac sympathetic innervation in this disorder in individuals with carotid sinus syndrome, asymptomatic carotid sinus hypersensitivity and controls without carotid sinus hypersensitivity. Methods Consecutive patients diagnosed with carotid sinus syndrome at a specialist falls and syncope unit were recruited. Asymptomatic carotid sinus hypersensitivity and non-carotid sinus hypersensitivity control participants recruited from a community-dwelling cohort. Cardiac sympathetic innervation was determined using Iodine-123-metaiodobenzylguanidine (123-I-MIBG) scanning. Heart to mediastinal uptake ratio (H:M) were determined for early and late uptake on planar scintigraphy at 20 minutes and 3 hours following intravenous injection of 123-I-MIBG. Results Forty-two subjects: carotid sinus syndrome (n = 21), asymptomatic carotid sinus hypersensitivity (n = 12) and no carotid sinus hypersensitivity (n = 9) were included. Compared to the non- carotid sinus hypersensitivity control group, the carotid sinus syndrome group had significantly higher early H:M (estimated mean difference, B = 0.40; 95% confidence interval, CI = 0.13 to 0.67, p = 0.005) and late H:M (B = 0.32; 95%CI = 0.03 to 0.62, p = 0.032). There was, however, no significant difference in early H:M (p = 0.326) or late H:M (p = 0.351) between the asymptomatic carotid sinus hypersensitivity group and non- carotid sinus hypersensitivity controls. Conclusions Cardiac sympathetic neuronal activity is increased relative to age-matched controls in individuals with carotid sinus syndrome but not those with asymptomatic carotid sinus hypersensitivity. Blood pressure and heart rate measurements alone may therefore represent an over simplification in the assessment for carotid sinus syndrome and the relative increase in cardiac sympathetic innervation provides additional clues to understanding the mechanisms behind the symptomatic presentation of carotid sinus hypersensitivity. PMID:26057525

[Vasovagal syncope as a cause of serious body injury - two case reports].

PubMed

Gajek, Jacek; Zyśko, Dorota

2003-04-01

Vasovagal syncope is a reflex reaction, leading to marked hypotension and/or bradycardia with transient loss of consciousness and the postural muscle tone. The recovery is spontaneous and usually rapid. Serious body injuries caused by fainting are rare. We present two patients with vasovagal syncope which caused serious injury. Different therapeutic options, including pacemaker implantation, are discussed.

An episode of syncope attacks in adolescent schoolgirls: investigations, intervention and outcome.

PubMed

Lee, P W; Leung, P W; Fung, A S; Low, L C; Tsang, M C; Leung, W C

1996-09-01

An increasing number of students in a secondary convent girls school developed syncope attacks over a time course of about two months. Fourteen students who suffered from syncope and 12 other students from the same class with no symptoms were assessed by a team of psychologists and paediatricians with the aim of identifying the cause of the problem and to formulate possible remedial action. Psychological assessments included a mental state examination, developmental, personal and psychological history, state-trait anxiety, self-esteem, hypnotic suggestibility, and students' beliefs about the cause and nature of the syncope attacks. Physical investigations included physical examination, blood pressure and electrocardiogram. The results indicated that most participants and controls had no physical or psychological pathologies. The two groups were not different on the physical and psychological measures. Analyses of the interview data, however, indicated that all the syncope sufferers belonged to a cohesive and exclusive social network. Social psychological circumstances rather than individual psychopathology were noted to be primarily responsible for the spread and maintenance of the mass hysterical influence. Intervention consisted of health education, authoritative reassurance and back-up support. Follow-up assessment after three and 12 months indicated no further syncope episodes.

[Controversies in the conduction and evaluation of clinical trials results for the treatment in vasovagal syncope].

PubMed

Gajek, Jacek; Zyśko, Dorota; Halawa, Bogumił

2003-05-01

The vasovagal syncope is a reflex reaction to various stimuli leading to the marked hypotension with or without bradycardia with loss of consciousness and fall of postural muscle tone. The vast majority of the patients recover spontaneously but if the syncope occurs frequently and causes injury of the patients body it worsens the quality of life and needs appropriate treatment. The injuries requiring hospitalization occur approximately in 10% of the patients with vasovagal syncope. The aim of the therapy of affected patients is to diminish the syncope prevalence, to brake the neurocardiogenic reaction on an early stage or to prolong the duration of the presyncope phase to enable the patient prevention of the injury. The lack of clear diagnostic criteria and difficulties with estimation the efficacy of any particular therapeutic intervention in many clinical studies of different authors, inclusion to the studies patients with different clinical presentation stages of the disease contribute to different conclusions, which automatic use in the clinical practice is inappropriate. There is an urgent need to clear the methodological discrepancies and to conduct good planed, large, randomized, multicentre studies to assess the efficacy of different therapeutic methods in the treatment of vasovagal syncope.

Jervell and Lange-Nielsen syndrome in a father and daughter from a large highly inbred family: a 16-year follow-up of 59 living members.

PubMed

Sanyal, Shyamal Kumar; Kaul, Kanwar K; Hussein, Akhtar; Wilroy, Robert S; Agarwal, Kisan; Sohel, Saira

2013-08-01

To report the autosomal dominant inheritance of the Jervell and Lange-Nielsen syndrome in a highly inbred family, the initiation of Torsades de Pointes, and the natural history of the syndrome based on a 16-year follow-up of the kindred. A family tree was constructed that included 66 blood relatives from three successive generations. Electrocardiograms were obtained from 59 living members including the proband, four members from a nuclear family, and 54 from the extended family. Evoked response audiometry was recorded for the proband and the nuclear family. All 59 family members were followed up regularly for 16 years. A total of 24 living members were affected--QTc: 480-680 ms. The proband had long QTc, bilateral high-tone sensorineural deafness, recurrent syncope, and Torsades de Pointes. The asymptomatic father had long QTc and unilateral high-tone sensorineural deafness that involved specifically the left ear. One asymptomatic sibling of the proband had long QTc and normal hearing. The mother and another sibling were asymptomatic; QTc and hearing were normal in both. A total of 21 affected members from the extended family had only long QTc, and all were asymptomatic. There were three congenitally deaf first cousins who had recurrent syncope and adrenergic-triggered sudden death. In all, seven of 10 parents had consanguineous marriage to a first cousin. Each affected offspring had at least one affected parent. The severely symptomatic proband who received only β-blocker therapy and the 23 affected members without antiadrenergic therapy, all remained asymptomatic throughout the 16-year follow-up period. Jervell and Lange-Nielsen syndrome was inherited as autosomal dominant in this kindred. The majority of the affected members had a mild phenotype. The severity of auditory and cardiac phenotypes corresponded.

Homozygous/Compound Heterozygous Triadin Mutations Associated With Autosomal-Recessive Long-QT Syndrome and Pediatric Sudden Cardiac Arrest: Elucidation of the Triadin Knockout Syndrome.

PubMed

Altmann, Helene M; Tester, David J; Will, Melissa L; Middha, Sumit; Evans, Jared M; Eckloff, Bruce W; Ackerman, Michael J

2015-06-09

Long-QT syndrome (LQTS) may result in syncope, seizures, or sudden cardiac arrest. Although 16 LQTS-susceptibility genes have been discovered, 20% to 25% of LQTS remains genetically elusive. We performed whole-exome sequencing child-parent trio analysis followed by recessive and sporadic inheritance modeling and disease-network candidate analysis gene ranking to identify a novel underlying genetic mechanism for LQTS. Subsequent mutational analysis of the candidate gene was performed with polymerase chain reaction, denaturing high-performance liquid chromatography, and DNA sequencing on a cohort of 33 additional unrelated patients with genetically elusive LQTS. After whole-exome sequencing and variant filtration, a homozygous p.D18fs*13 TRDN-encoded triadin frameshift mutation was discovered in a 10-year-old female patient with LQTS with a QTc of 500 milliseconds who experienced recurrent exertion-induced syncope/cardiac arrest beginning at 1 year of age. Subsequent mutational analysis of TRDN revealed either homozygous or compound heterozygous frameshift mutations in 4 of 33 unrelated cases of LQTS (12%). All 5 TRDN-null patients displayed extensive T-wave inversions in precordial leads V1 through V4, with either persistent or transient QT prolongation and severe disease expression of exercise-induced cardiac arrest in early childhood (≤3 years of age) and required aggressive therapy. The overall yield of TRDN mutations was significantly greater in patients ≤10 years of age (5 of 10, 50%) compared with older patients (0 of 24, 0%; P=0.0009). We identified TRDN as a novel underlying genetic basis for recessively inherited LQTS. All TRDN-null patients had strikingly similar phenotypes. Given the recurrent nature of potential lethal arrhythmias, patients fitting this phenotypic profile should undergo cardiac TRDN genetic testing. © 2015 American Heart Association, Inc.

[Adverse reactions to human papillomavirus vaccine in the Valencian Community (2007-2011)].

PubMed

Rodríguez-Galán, M A; Pérez-Vilar, S; Díez-Domingo, J; Tuells, J; Gomar-Fayos, J; Morales-Olivas, F; Pastor-Villalba, E

2014-11-01

In 2009, two cases of seizures in adolescents following quadrivalent human papillomavirus vaccine (qHPV) administration, generated important media attention, and adversely affected public trust in this vaccine. Our objectives were to describe suspected adverse reactions (SARs) reported to the Pharmacovigilance Centre in the Valencian Community (PCVC) after administration of HPV vaccine, and to compare reporting rates of syncope and seizures following this vaccine with those of other vaccines administered to girls aged 13-15 years. Descriptive study of SARs reported following this vaccine to the PCVC between 2007 and 2011. The clinical symptoms most frequently reported were dizziness, headache, and syncope. Reporting rates of syncope or loss of consciousness and seizures with qHPV vaccine were 17 and 3.2 per 100,000 doses administered, respectively, and 15 and 1.6 for syncope or loss of consciousness and syncopal seizures occurred on the day of vaccination. The reporting rates of syncope or loss of consciousness and seizures were 6.4 and 0.4, for the other vaccines. Consistent with the media attention generated, and with results from other studies, the reporting rates of syncope or loss of consciousness and seizures were higher for the HPV vaccine than for other vaccines given in adolescence. Nevertheless, the overall information obtained on SARs following the qHPV vaccine suggests a good safety profile. Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.

Bradycardia, Syncope, and Left Ventricular Noncompaction Cardiomyopathy.

PubMed

Glancy, D Luke; Helmcke, Frederick R; Hoang, Allen P

2017-08-15

A 55-year-old man with syncopal episodes was found to have sinus bradycardia at a rate of 37 beats/min, an episode of nonsustained ventricular tachycardia, and left ventricular noncompaction cardiomyopathy. After placement of a dual-chamber cardioverter defibrillator 4 years ago, he has had no further syncopal episodes, and there have been no defibrillator shocks. Copyright © 2017 Elsevier Inc. All rights reserved.

Operating theatre related syncope in medical students: a cross sectional study

PubMed Central

Jamjoom, AAB; Nikkar-Esfahani, A; Fitzgerald, JEF

2009-01-01

Background Observing surgical procedures is a beneficial educational experience for medical students during their surgical placements. Anecdotal evidence suggests that operating theatre related syncope may have detrimental effects on students' views of this. Our study examines the frequency and causes of such syncope, together with effects on career intentions, and practical steps to avoid its occurrence. Methods All penultimate and final year students at a large UK medical school were surveyed using the University IT system supplemented by personal approach. A 20-item anonymous questionnaire was distributed and results were analysed using the Statistical Package for Social Sciences, version 15.0 (Chicago, Illinois, USA). Results Of the 630 clinical students surveyed, 77 responded with details of at least one near or actual operating theatre syncope (12%). A statistically significant gender difference existed for syncopal/near-syncopal episodes (male 12%; female 88%), p < 0.05. Twenty-two percent of those affected were graduate entry medical course students with the remaining 78% undergraduate. Mean age was 23-years (range 20 – 45). Of the 77 reactors, 44 (57%) reported an intention to pursue a surgical career. Of this group, 7 (9%) reported being discouraged by syncopal episodes in the operating theatre. The most prevalent contributory factors were reported as hot temperature (n = 61, 79%), prolonged standing (n = 56, 73%), wearing a surgical mask (n = 36, 47%) and the smell of diathermy (n = 18, 23%). The most frequently reported measures that students found helpful in reducing the occurrence of syncopal episodes were eating and drinking prior to attending theatre (n = 47, 61%), and moving their legs whilst standing (n = 14, 18%). Conclusion Our study shows that operating theatre related syncope among medical students is common, and we establish useful risk factors and practical steps that have been used to prevent its occurrence. Our study also highlights the detrimental effect of this on the career intentions of medical students interested in surgery. Based on these findings, we recommend that dedicated time should be set aside in surgical teaching to address this issue prior to students attending the operating theatre. PMID:19284564

Operating theatre related syncope in medical students: a cross sectional study.

PubMed

Jamjoom, A A B; Nikkar-Esfahani, A; Fitzgerald, J E F

2009-03-10

Observing surgical procedures is a beneficial educational experience for medical students during their surgical placements. Anecdotal evidence suggests that operating theatre related syncope may have detrimental effects on students' views of this. Our study examines the frequency and causes of such syncope, together with effects on career intentions, and practical steps to avoid its occurrence. All penultimate and final year students at a large UK medical school were surveyed using the University IT system supplemented by personal approach. A 20-item anonymous questionnaire was distributed and results were analysed using the Statistical Package for Social Sciences, version 15.0 (Chicago, Illinois, USA). Of the 630 clinical students surveyed, 77 responded with details of at least one near or actual operating theatre syncope (12%). A statistically significant gender difference existed for syncopal/near-syncopal episodes (male 12%; female 88%), p < 0.05. Twenty-two percent of those affected were graduate entry medical course students with the remaining 78% undergraduate. Mean age was 23-years (range 20 - 45). Of the 77 reactors, 44 (57%) reported an intention to pursue a surgical career. Of this group, 7 (9%) reported being discouraged by syncopal episodes in the operating theatre. The most prevalent contributory factors were reported as hot temperature (n = 61, 79%), prolonged standing (n = 56, 73%), wearing a surgical mask (n = 36, 47%) and the smell of diathermy (n = 18, 23%). The most frequently reported measures that students found helpful in reducing the occurrence of syncopal episodes were eating and drinking prior to attending theatre (n = 47, 61%), and moving their legs whilst standing (n = 14, 18%). Our study shows that operating theatre related syncope among medical students is common, and we establish useful risk factors and practical steps that have been used to prevent its occurrence. Our study also highlights the detrimental effect of this on the career intentions of medical students interested in surgery. Based on these findings, we recommend that dedicated time should be set aside in surgical teaching to address this issue prior to students attending the operating theatre.

Hypovolemic intolerance to lower body negative pressure in female runners.

PubMed

Morikawa, T; Sagawa, S; Torii, R; Endo, Y; Yamazaki, F; Shiraki, K

2001-12-01

An attenuated baroreflex response and orthostatic intolerance have been reported in endurance-trained male athletes; however, it is still unknown whether this occurs also in females. The purpose of the present study was to examine whether endurance exercise-trained women had a predisposition to orthostatic compromise, and if so, what causative factor(s) may induce orthostatic intolerance. We studied cardiovascular and hormonal responses to graded lower body negative pressure (LBNP) (0 to -60 mm Hg) in 26 middle-distance female runners (18.6 +/- 0.1 yr) as the exercise-trained (ET) subjects and 23 age-matched untrained (UT) control subjects. On the basis of the occurrence of syncope episodes during LBNP, ET and UT subjects were further allocated to two groups; ET with presyncope (ET+syncope) and without presyncope (ET-syncope) and UT with presyncope (UT+syncope) and without presyncope (UT-syncope). Occurrence of presyncope episodes during LBNP was higher in ET (65.4%, P < 0.05) than that for UT (34.8%). Leg compliance was higher (P < 0.05) in ET than in UT. LBNP reduced stroke volume (SV) more (P < 0.05), increased heart rate (HR) higher (P < 0.05), and increased forearm vascular resistance (FVR) more in ET+syncope as compared with the other groups. Response of vasoactive hormones to LBNP was higher in ET+syncope (P < 0.05) than that of the other groups except for norepinephrine (NE); high in both ET+syncope and UT+syncope. The relationship between SV and NE, an index of sympathetic neuronal response, had no training-related changes during LBNP. We conclude that exercise-trained females have a high incidence of orthostatic intolerance during LBNP, with a greater reduction of SV independent of changes in baroreflex and neurohumoral function. A lower incidence of LBNP intolerance in UT may be accounted for by a lower reduction of SV during LBNP. An increase in leg compliance in the exercise-trained females may play an important role in inducing pronounced reduction of SV and hence the intolerance to LBNP.

[Adrenomedullin--the link between the sympathetic nervous system activation and peripheral vasodilatation in some patients with vasovagal syncope].

PubMed

Gajek, Jacek; Zyśko, Dorota; Halawa, Bogumił

2004-09-01

Adrenomedullin (ADM) is a potent vasodilator playing role in regulation of central hemodynamic. The concentration of plasma ADM in healthy people increases under the influence of orthostatic stress. In patients with vasovagal syncope (VS) the changes in ADM concentration could be responsible either for syncope provocation or prevention. The aim of the study was to assess the influence of phase of the head-up tilt test (HUTT) in which the syncope occurred on the plasma concentration of ADM. The study was performed in 25 patients (pts) (18 women and 7 men), mean age 45.0+/-16.1 years with cardiodepressive reactions during HUTT according to the Italian protocol with nitroglycerine (NTG) provocation if necessary: Syncope was caused in 23 pts due to vasovagal reaction: in 17 pts syncope occurred after NTG provocation (group 1), and in 6 pts occurred in the passive phase of tilt (group 2a), in 2 pts due to dysautonomic reactions (group 2b). The head-up tilt test was performed according to ESC guidelines. The blood for ADM concentration was drawn after 30 min supine rest (ADM 1) and immediately after syncope (ADM 2). ADM level was measured using radioimmunological method. The results. In group 1 plasma level of ADM significantly decreased after the HUTT (3.2+/-3.4 vs 1.7+/-1,4 pg/0.1 ml; p<0.05) and in group 2a increased significantly (1.3+/-0.8 vs 2.7+/-1.3 pg/0.1 ml; p<0.05) comparing to baseline values. The ADM concentration did not differ between the groups in baseline conditions and was significantly higher after the syncope in group 2a (p<0.05). Conclusions. The excessive increase of ADM concentration during the passive phase of HUTT could play the causative role in pathogenesis of VS occurring early during the HUTT. In patients with VS after NTG provocation the decrease of ADM concentration can be the result of hemodynamic changes in the presence of vasodilating drug and may be the mechanism that could prevent the syncope.

Syncope or seizure? The diagnostic value of the EEG and hyperventilation test in transient loss of consciousness.

PubMed Central

Hoefnagels, W A; Padberg, G W; Overweg, J; Roos, R A; van Dijk, J G; Kamphuisen, H A

1991-01-01

In a prospective study of consecutive patients (age 15 or over) with transient loss of consciousness 45 patients had a history of seizure and 74 patients had a history of syncope. All patients had an EEG, ECG, laboratory tests and a hyperventilation test and were followed for an average of 14.5 months. Epileptiform activity in the interictal EEG had a sensitivity of 0.40 and a specificity of 0.95 for the diagnosis of a seizure. Epileptiform activity nearly doubled the probability of a seizure in doubtful cases. If no epileptiform activity was found, this probability remained substantially the same. The hyperventilation test had a sensitivity of 0.57 and a specificity of 0.84 for the diagnosis of syncope. A positive test increased the probability of syncope half as much in doubtful cases. A negative test did not exclude syncope. Laboratory tests were not helpful except for an ECG which was helpful in elderly patients. PMID:1800665

[Rabdomiosarcoma primario de corazón como causa de síncope recurrente en el adulto].

PubMed

Díaz-Pérez, Julio Alexander; Gómez-Arbeláez, Diego; Hurtado-Gomez, Gabriel Alexander

2011-01-01

Primary or secondary neoplasms can affect the heart. Secondary are more common. However, primary neoplasms are relevant because is a group with diverse genesis, behavior, treatment and clinical manifestations. We present a case of a 45 year-old woman, with recurrent syncope started 1 year before her first consult. She had palpitations and chest pain. Echocardiography identified a left atrium mass of 2.1x1.8 cm. Endomyocardial biopsy document a primary rhabdomyosarcoma of the heart. The patient dies after a overall-survival of 22 months. This case presented had a good study of its symptoms with an accurate diagnosis and early treatment, which provided prolonged survival of this rare and aggressive neoplasm.

Pulmonary thromboembolism in a patient with active ulcerative colitis and lung abscess secondary to pulmonary infarction.

PubMed

Asker, Selvi; Gunbatar, Hulya; Ekin, Selami; Sertogullarindan, Bunyamin; Sunnetcioglu, Aysel

2014-12-01

Crohn's disease and ulcerative colitis are inflammatory bowel diseases and they primarily involve intestines. Herein we report the case of a young man who, during a clinical recurrence of ulcerative colitis, presented with symptoms suggestive of a lung abscess. When the patient was re-evaluated because of unexplained shortness of breath, an area of infarction was detected that had led to the development of cavitation secondary to submassive embolism and foci of infection contained within. The patient was managed with subcutaneous heparin and he was asymptomatic during 2 months of follow-up. He completed six months of anti-coagulation therapy and any recurrence was not detected during 3 months of post-treatment follow-up.

Clinically oriented device programming in bradycardia patients: part 2 (atrioventricular blocks and neurally mediated syncope). Proposals from AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

PubMed

Palmisano, Pietro; Ziacchi, Matteo; Biffi, Mauro; Ricci, Renato P; Landolina, Maurizio; Zoni-Berisso, Massimo; Occhetta, Eraldo; Maglia, Giampiero; Botto, Gianluca; Padeletti, Luigi; Boriani, Giuseppe

2018-04-01

: The purpose of this two-part consensus document is to provide specific suggestions (based on an extensive literature review) on appropriate pacemaker setting in relation to patients' clinical features. In part 2, criteria for pacemaker choice and programming in atrioventricular blocks and neurally mediate syncope are proposed. The atrioventricular blocks can be paroxysmal or persistent, isolated or associated with sinus node disease. Neurally mediated syncope can be related to carotid sinus syndrome or cardioinhibitory vasovagal syncope. In sinus rhythm, with persistent atrioventricular block, we considered appropriate the activation of mode-switch algorithms, and algorithms for auto-adaptive management of the ventricular pacing output. If the atrioventricular block is paroxysmal, in addition to algorithms mentioned above, algorithms to maximize intrinsic atrioventricular conduction should be activated. When sinus node disease is associated with atrioventricular block, the activation of rate-responsive function in patients with chronotropic incompetence is appropriate. In permanent atrial fibrillation with atrioventricular block, algorithms for auto-adaptive management of the ventricular pacing output should be activated. If the atrioventricular block is persistent, the activation of rate-responsive function is appropriate. In carotid sinus syndrome, adequate rate hysteresis should be programmed. In vasovagal syncope, specialized sensing and pacing algorithms designed for reflex syncope prevention should be activated.

Syncope among U.S. Air Force basic military trainees, August 2012-July 2013.

PubMed

Webber, Bryant J; Cropper, Thomas L; Federinko, Susan P

2013-11-01

Syncope is a common event with many possible etiologies, ranging from benign to severe. Syncopal episodes of any origin, however, may result in traumatic injury due to postural collapse. Based on the prevalence of internal and external stressors during training, basic military trainees may be at increased risk for syncope. Between 1 August 2012 and 31 July 2013, there were 112 unique individuals who experienced syncopal or pre-syncopal events among basic military trainees at Joint Base San Antonio-Lackland, Texas, the only basic training site in the U.S. Air Force. The overall rate was 19.6 cases per 1,000 person-years (18.4 and 36.1 per 1,000 person-years in males and females, respectively). Based upon the findings of electronic chart review of the 112 cases, a majority of events occurred either during or immediately after exercise (n=38) or during a blood draw, immunization, or laceration repair (n=22). The most common etiologies were judged to be neurocardiogenic (n=54) and orthostatic hypotension (n=40), and two cases were attributed to cardiovascular disease. These findings support current preventive measures, including anemia screening during medical in-processing, an emphasis on hydration throughout training, and a padded floor in the trainee vaccination bay.

Luteal phase HCG support for unexplained recurrent pregnancy loss - a low hanging fruit?

PubMed

Fox, Chelsea; Azores-Gococo, Denise; Swart, Linda; Holoch, Kristin; Savaris, Ricardo F; Likes, Creighton E; Miller, Paul B; Forstein, David A; Lessey, Bruce A

2017-03-01

Recurrent pregnancy loss (RPL) is defined by two or more failed pregnancies and accounts for only 1-5% of pregnancy failures. Treatment options for unexplained RPL (uRPL) are limited. Previous studies suggest a link between delayed implantation and pregnancy loss. Based on this, a timely signal for rescue of the corpus luteum (CL) using human chorionic gonadotrophin (HCG) could improve outcomes in women with uRPL. This retrospective cohort study included 98 subjects with uRPL: 45 underwent 135 monitored cycles without HCG support; and 53 underwent 142 cycles with a single mid-luteal HCG injection. Based on Log-rank Mantel-Cox survival curves, miscarriage rate and time to pregnancy decreased in the HCG group (P = 0.0005). Women receiving luteal HCG support had an increased chance of an ongoing pregnancy compared with those not receiving it (RR = 2.4; 95% CI 1.4-3.6; number need to treat (NNT) = 7; 95% CI 4-18). Subjects receiving HCG support had a significant absolute risk reduction (ARR) of miscarriage (P < 0.001; ARR = 11.5%; 95% CI 3.6-19.5; NNT = 9(5-27). These data suggest restoration of synchrony and CL support improves outcomes in women with RPL. Further randomized controlled trials of luteal-phase HCG in women with RPL appears warranted. Copyright © 2016 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Antinuclear Antibodies predict a higher number of Pregnancy Loss in Unexplained Recurrent Pregnancy Loss.

PubMed

Sakthiswary, R; Rajalingam, S; Norazman, M R; Hussein, H

The etiology of recurrent pregnancy loss (RPL) is unknown in a significant proportion of patients. Autoimmune processes have been implicated in the pathogenesis. The role of antinuclear antibody (ANA) in this context is largely undetermined. In an attempt to address the lack of evidence in this area, we explored the clinical significance of antinuclear antibody (ANA) in unexplained RPL. We studied 68 patients with RPL and 60 healthy controls from September 2005 to May 2012. All subjects were tested for ANA by immunofluorescence testing, and a titer of 1: 80 and above was considered positive. We compared the pregnancy outcome between the ANA positive and ANA negative RPL cases. The incidence of ANA positivity among the cases (35.3%) was significantly higher than the controls (13.3%) (p=0.005). ANA positive cases showed significantly higher number of RPL (p=0.006) and lower number of successful pregnancies (p=0.013) compared to the ANA negative cases . The ANA titre had a significant association with the number of RPL (p<0.05, r=0.724) but not with the number of successful pregnancies (p=0.054). ANA positivity predicts a less favorable pregnancy outcome in RPL. Our findings suggest that the ANA titre is a useful positive predictor of the number of RPL. Hence, ANA test is a potential prognostic tool for this condition which merits further research.

An Evaluation of Factors Associated With Pathogenic PRSS1, SPINK1, CTFR, and/or CTRC Genetic Variants in Patients With Idiopathic Pancreatitis.

PubMed

Jalaly, Niloofar Y; Moran, Robert A; Fargahi, Farshid; Khashab, Mouen A; Kamal, Ayesha; Lennon, Anne Marie; Walsh, Christi; Makary, Martin A; Whitcomb, David C; Yadav, Dhiraj; Cebotaru, Liudmila; Singh, Vikesh K

2017-08-01

We evaluated factors associated with pathogenic genetic variants in patients with idiopathic pancreatitis. Genetic testing (PRSS1, CFTR, SPINK1, and CTRC) was performed in all eligible patients with idiopathic pancreatitis between 2010 to 2015. Patients were classified into the following groups based on a review of medical records: (1) acute recurrent idiopathic pancreatitis (ARIP) with or without underlying chronic pancreatitis; (2) idiopathic chronic pancreatitis (ICP) without a history of ARP; (3) an unexplained first episode of acute pancreatitis (AP)<35 years of age; and (4) family history of pancreatitis. Logistic regression analysis was used to determine the factors associated with pathogenic genetic variants. Among 197 ARIP and/or ICP patients evaluated from 2010 to 2015, 134 underwent genetic testing. A total of 88 pathogenic genetic variants were found in 64 (47.8%) patients. Pathogenic genetic variants were identified in 58, 63, and 27% of patients with ARIP, an unexplained first episode of AP <35 years of age, and ICP without ARP, respectively. ARIP (OR: 18.12; 95% CI: 2.16-151.87; P=0.008) and an unexplained first episode of AP<35 years of age (OR: 2.46; 95% CI: 1.18-5.15; P=0.017), but not ICP, were independently associated with pathogenic genetic variants in the adjusted analysis. Pathogenic genetic variants are most likely to be identified in patients with ARIP and an unexplained first episode of AP<35 years of age. Genetic testing in these patient populations may delineate an etiology and prevent unnecessary diagnostic testing and procedures.

A hairy fall: syncope resulting from topical application of minoxidil

PubMed Central

Dubrey, S W; VanGriethuysen, J; Edwards, C M B

2015-01-01

We describe the case of a young man who developed syncope after using a high strength formulation of topical minoxidil as a hair growth restorer. Other potential cardiovascular and endocrine causes were excluded, and his symptoms resolved on discontinuation of the product. While syncope is a recognised side effect of using this powerful systemic antihypertensive agent, few cases are documented in the literature, which we illustrate in our discussion. PMID:26347235

Microneurographic evidence of sudden sympathetic withdrawal in carotid sinus syncope; treatment with ergotamine

NASA Technical Reports Server (NTRS)

Costa, F.; Biaggioni, I.

1994-01-01

A proportion of patients with carotid sinus syncope (CSS) remain symptomatic even after pacemaker implantation because of persistence of a vasodepressor component. We report a patient with CSS whose syncopal episodes could be reproduced by carotid sinus massage and were due to profound hypotension associated with sudden sympathetic withdrawal, based on direct measurements of sympathetic nerve traffic. A double-blind trial with inhaled ergotamine provided significant symptomatic relief.

[Clonazepam in therapy of neurogenic syncopal states].

PubMed

Musaeva, Z A

2001-01-01

27 patients with frequent neurogenic syncopes (NS) resistant to conventional therapy were treated with clonazepam. The average age of the patients was 29.8 +/- 11.6 years. There were 1-2 syncopes in a month. Both before and after the treatment an active orthostatic test was performed with ECG registration and following analysis of variability of the cardiac rhythm. Clonazepam was administered in a dose of 2-2.5 mg/day during 8-9 weeks. Clinical improvement in the form of a lack of syncopes was observed in 20 patients (74%); 3 patients (10%) had isolated lipothymic states; 2 patients discontinued the treatment because of side-effects (dizziness). The results of the examination of 23 patients 6 months after clonazepam therapy testified the stability of the therapeutic effect.

[Technical options of electrotherapy in patients with vasovagal syncope].

PubMed

Bałczewska, Daria; Kaczmarek, Krzysztof; Ptaszyński, Paweł; Wranicz, Jerzy Krzysztof; Cygankiewicz, Iwona

2016-10-19

Syncope is a symptom of the disease with diverse etiology and can be evidence of both benign and very serious life-threatening conditions. Vasovagal syncope(VVS), with prevalence about 35% of the general population, is most frequent causes of transient loss of consciousness (T-LOC). Most cases of vasovagal syncope requires conservative treatment. Although cardioinhibitory type of VVS characterized by a significant bradycardia or pause of the heart rate and can be treated with continuous electrotherapy. This article discuss cardiac pacing and technical solutions for the treatment of VVS. Available cardiac pacing methods used to detect and break VVS such as Rate Drop Response (RDR), Closed Loop Stimulation (CLS) and rate response driven by variations of myocardial contractility like Peak Endocardial Acceleration (PEA), has been presented.

Recurrent Fever in Children

PubMed Central

Torreggiani, Sofia; Filocamo, Giovanni; Esposito, Susanna

2016-01-01

Children presenting with recurrent fever may represent a diagnostic challenge. After excluding the most common etiologies, which include the consecutive occurrence of independent uncomplicated infections, a wide range of possible causes are considered. This article summarizes infectious and noninfectious causes of recurrent fever in pediatric patients. We highlight that, when investigating recurrent fever, it is important to consider age at onset, family history, duration of febrile episodes, length of interval between episodes, associated symptoms and response to treatment. Additionally, information regarding travel history and exposure to animals is helpful, especially with regard to infections. With the exclusion of repeated independent uncomplicated infections, many infective causes of recurrent fever are relatively rare in Western countries; therefore, clinicians should be attuned to suggestive case history data. It is important to rule out the possibility of an infectious process or a malignancy, in particular, if steroid therapy is being considered. After excluding an infectious or neoplastic etiology, immune-mediated and autoinflammatory diseases should be taken into consideration. Together with case history data, a careful physical exam during and between febrile episodes may give useful clues and guide laboratory investigations. However, despite a thorough evaluation, a recurrent fever may remain unexplained. A watchful follow-up is thus mandatory because new signs and symptoms may appear over time. PMID:27023528

Recurrent Fever in Children.

PubMed

Torreggiani, Sofia; Filocamo, Giovanni; Esposito, Susanna

2016-03-25

Children presenting with recurrent fever may represent a diagnostic challenge. After excluding the most common etiologies, which include the consecutive occurrence of independent uncomplicated infections, a wide range of possible causes are considered. This article summarizes infectious and noninfectious causes of recurrent fever in pediatric patients. We highlight that, when investigating recurrent fever, it is important to consider age at onset, family history, duration of febrile episodes, length of interval between episodes, associated symptoms and response to treatment. Additionally, information regarding travel history and exposure to animals is helpful, especially with regard to infections. With the exclusion of repeated independent uncomplicated infections, many infective causes of recurrent fever are relatively rare in Western countries; therefore, clinicians should be attuned to suggestive case history data. It is important to rule out the possibility of an infectious process or a malignancy, in particular, if steroid therapy is being considered. After excluding an infectious or neoplastic etiology, immune-mediated and autoinflammatory diseases should be taken into consideration. Together with case history data, a careful physical exam during and between febrile episodes may give useful clues and guide laboratory investigations. However, despite a thorough evaluation, a recurrent fever may remain unexplained. A watchful follow-up is thus mandatory because new signs and symptoms may appear over time.

Chinese herbal medicines for unexplained recurrent miscarriage.

PubMed

Li, Lu; Dou, Lixia; Leung, Ping Chung; Chung, Tony Kwok Hung; Wang, Chi Chiu

2016-01-14

Recurrent miscarriage affects 1% to 3% of women of reproductive age and mostly occurs before the 10th week of gestation (and around the same gestational week in subsequent miscarriages). Although most pregnant women may not recognise a miscarriage until uterine bleeding and cramping occur, a repeat miscarriage after one or more pregnancy loss and the chance of having a successful pregnancy varies. To date, there is no universally accepted treatment for unexplained recurrent miscarriage. Chinese herbal medicines have been widely used in Asian societies for millennia and have become a popular alternative to Western medicines in recent years. Many clinical studies have reported that Chinese herbal medicines can improve pregnancy outcomes for pregnant women who had previously suffered recurrent miscarriage. This systematic review evaluated the efficacy of Chinese herbal medicines for recurrent miscarriage. To assess the effectiveness and safety of Chinese herbal medicines for the treatment of unexplained recurrent miscarriage. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (01 June 2015), Embase (1980 to 01 June 2015); Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 01 June 2015); Chinese Biomedical Database (CBM) (1978 to 01 June 2015); China Journal Net (CJN) (1915 to 01 June 2015); China Journals Full-text Database (1915 to 01 June 2015); and WanFang Database (Chinese Ministry of Science & Technology) (1980 to 01 June 2015). We also searched reference lists of relevant trials and reviews. We identified and contacted organisations, individual experts working in the field, and medicinal herb manufacturers. Randomised or quasi-randomised controlled trials, including cluster-randomised trials, with or without full text, comparing Chinese herbal medicines (alone or combined with other intervention or other pharmaceuticals) with placebo, no treatment, other intervention (including bed rest and psychological support), or other pharmaceuticals as treatments for unexplained recurrent miscarriage. Cross-over studies were not eligible for inclusion in this review. Two review authors independently assessed all the studies for inclusion in the review, assessed risk of bias and extracted the data. Data were checked for accuracy. We included nine randomised clinical trials (involving 861 women). The trials compared Chinese herbal medicines (various formulations) either alone (one trial), or in combination with other pharmaceuticals (seven trials) versus other pharmaceuticals alone. One study compared Chinese herbal medicines and other pharmaceuticals versus psychotherapy. We did not identify any trials comparing Chinese herbal medicines with placebo or no treatment, including bed rest.Various Chinese herbal medicines were used in the different trials (and some of the classical the formulations were modified in the trials). The Western pharmaceutical medicines included tocolytic drugs such as salbutamol and magnesium sulphate; hormonal supplementation with human chorionic gonadotrophin (HCG), progesterone or dydrogesterone; and supportive supplements such as vitamin E, vitamin K and folic acid.Overall, the methodological quality of the included studies was poor with unclear risk of bias for nearly all the 'Risk of bias' domains assessed.Chinese herbal medicines alone versus other pharmaceuticals alone - the live birth rate was no different between the two groups (risk ratio (RR) 1.05; 95% confidence interval (CI) 0.67 to 1.65; one trial, 80 women). No data were available for the outcome of pregnancy rate (continuation of pregnancy after 20 weeks of gestation).In contrast, the continuing pregnancy rate (RR 1.27 95% CI 1.10 to 1.48, two trials, 189 women) and live birth rate (average RR 1.55; 95% CI 1.14 to 2.10; six trials, 601 women, Tau² = 0.10; I² = 73%) were higher among the group of women who received a combination of Chinese herbal medicines and other pharmaceuticals when compared with women who received other pharmaceuticals alone.For Chinese herbal medicines and psychotherapy versus psychotherapy alone (one study) - there was a higher live birth rate (RR 1.32; 95% CI 1.07 to 1.64; one trial, 90 women) in the group of women who received a combination of Chinese herbal medicines and psychotherapy compared to those women who received psychotherapy alone. No data were available on the continuing pregnancy rate for this comparison.Other primary outcomes (maternal adverse effect and toxicity rate and the perinatal adverse effect and toxicity rate) were not reported in most of the included studies. Two trials (341 women) reported that no maternal adverse effects were found (one trial compared (combined) medicines with other pharmaceuticals, and one trial compared combined Chinese herbal medicine alone versus other pharmaceuticals). One trial (Chinese herbal medicine alone versus other pharmaceuticals alone) reported that there were no abnormal fetuses (ultrasound) or after delivery.There were no data reported for any of this review's secondary outcomes. We found limited evidence (from nine studies with small sample sizes and unclear risk of bias) to assess the effectiveness of Chinese herbal medicines for treating unexplained recurrent miscarriage; no data were available to assess the safety of the intervention for the mother or her baby. There were no data relating to any of this review's secondary outcomes. From the limited data we found, a combination of Chinese herbal medicines and other pharmaceuticals (mainly Western medicines) may be more effective than Western medicines alone in terms of the rate of continuing pregnancy and the rate of live births. However, the methodological quality of the included studies was generally poor.A comparison of Chinese herbal medicines alone versus placebo or no treatment (including bed rest) was not possible as no relevant trials were identified.More high-quality studies are needed to further evaluate the effectiveness and safety of Chinese herbal medicines for unexplained recurrent miscarriage. In addition to assessing the effect of Chinese herbal medicines on pregnancy rate and the rate of live births, future studies should also consider safety issues (adverse effects and toxicity for the mother and her baby) as well as the secondary outcomes listed in this review. This review would provide more valuable information if the included studies could overcome the problems in their designs, such as lacking of qualified placebo-controlled trials, applying adequate randomisation methods and avoiding potential bias.

Diagnosis and management of adult hereditary cardio-neuromuscular disorders: A model for the multidisciplinary care of complex genetic disorders.

PubMed

Sommerville, R Brian; Vincenti, Margherita Guzzi; Winborn, Kathleen; Casey, Anne; Stitziel, Nathan O; Connolly, Anne M; Mann, Douglas L

2017-01-01

Genetic disorders that disrupt the structure and function of the cardiovascular system and the peripheral nervous system are common enough to be encountered in routine cardiovascular practice. Although often these patients are diagnosed in childhood and come to the cardiologist fully characterized, some patients with hereditary neuromuscular disease may not manifest until adulthood and will present initially to the adult cardiologist for an evaluation of an abnormal ECG, unexplained syncope, LV hypertrophy, and or a dilated cardiomyopathy of unknown cause. Cardiologists are often ill-equipped to manage these patients due to lack of training and exposure as well as the complete absence of practice guidelines to aid in the diagnosis and management of these disorders. Here, we review three key neuromuscular diseases that affect the cardiovascular system in adults (myotonic dystrophy type 1, Friedreich ataxia, and Emery-Dreifuss muscular dystrophy), with an emphasis on their clinical presentation, genetic and molecular pathogenesis, and recent important research on medical and interventional treatments. We also advocate the development of interdisciplinary cardio-neuromuscular clinics to optimize the care for these patients. Copyright © 2016 Elsevier Inc. All rights reserved.

[Early recurrent miscarriage: Evaluation and management].

PubMed

Gallot, V; Nedellec, S; Capmas, P; Legendre, G; Lejeune-Saada, V; Subtil, D; Nizard, J; Levêque, J; Deffieux, X; Hervé, B; Vialard, F

2014-12-01

To establish recommendations for early recurrent miscarriages (≥3 miscarriages before 14weeks of amenorrhea). Literature review, establishing levels of evidence and recommendations for grades of clinical practice. Women evaluation includes the search for a diabetes (grade A), an antiphospholipid syndrome (APS) (grade A), a thyroid dysfunction (grade A), a hyperprolactinemia (grade B), a vitamin deficiency and a hyperhomocysteinemia (grade C), a uterine abnormality (grade C), an altered ovarian reserve (grade C), and a couple chromosome analysis (grade A). For unexplained early recurrent miscarriages, treatment includes folic acid and progesterone supplementation, and a reinsurance policy in the first quarter (grade C). It is recommended to prescribe the combination of aspirin and low-molecular-weight heparin when APS (grade A), glycemic control in diabetes (grade A), L-Thyroxine in case of hypothyroidism (grade A) or the presence of thyroid antibodies (grade B), bromocriptine if hyperprolactinemia (grade B), a substitution for vitamin deficiency or hyperhomocysteinemia (grade C), sectionning a uterine septum (grade C) and treating an uterine acquired abnormality (grade C). These recommendations should improve the management of couples faced with early recurrent miscarriages. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

[Tips for taking the medical history in patients with syncope].

PubMed

Israel, Carsten W

2018-06-01

Transient loss of consciousness represents one of the most frequent reasons for patients to present in the emergency room. Already at the very beginning, the diagnostic work-up is faced with fundamental questions: (1) Was it really a loss of consciousness? (2) Which department (neurology, cardiology, or others) should check the patient? (3) Is an in-hospital diagnostic work-up required? These questions can be answered from a meticulous patient history which needs to be adjusted to the individual case but also has to systematically go through a list of questions. Patient history has to clarify whether syncope was present. Nonsyncopal events such as falls, transient global amnesia, epilepsy, psychogenic pseudosyncope, transient ischemic attack and drop attacks should be distinguished. In a second step, the four groups of causes of syncope can be assessed. Neurocardiogenic reflex syncope usually occurs with typical prodromes in typical situations in (younger) patients without heart disease. Orthostasis always occurs in upright position, typically associated with standing up and in patients treated with antihypertensive drugs. Arrhythmogenic syncope frequently shows an abrupt onset without prodromes, associated with injury and with palpitations or fast heart beat before the attack, in older patients frequently associated with known heart disease, in young patients without heart disease frequently with a family history positive for arrhythmias or sudden cardiac death. A positive history of structural cardiovascular disease should be considered as a cause of syncope, particularly if it occurs during exercise or in supine position, or is associated with chest pain or dyspnea. This review summarizes the most important questions that can elucidate the cause of syncope.

Diagnostic utility of carotid artery duplex ultrasonography in the evaluation of syncope: a good test ordered for the wrong reason.

PubMed

Kadian-Dodov, Daniella; Papolos, Alexander; Olin, Jeffrey W

2015-06-01

Syncope refers to a transient loss of consciousness and postural tone secondary to cerebral hypoperfusion. Guidelines recommend against neurovascular testing in cases of syncope without neurologic symptoms; however, many pursue carotid artery duplex ultrasonography (CUS) due to the prognostic implications of identified cerebrovascular disease. Our objective was to determine the diagnostic utility of CUS in the evaluation of syncope and the identification of new or severe atherosclerosis with the potential to change patient management. We reviewed records of 569 patients with CUS ordered for the primary indication of syncope through an accredited vascular laboratory at an academic, urban medical centre. Findings on CUS, patient demographic, clinical and laboratory information, and medications within 6 months of the CUS exam were reviewed. Bivariate relationships between key medical history characteristics and atherosclerosis status (known vs. new disease) were examined. Among 495 patients with complete information, cerebrovascular findings could potentially explain syncope in 2% (10 patients). Optimization of cardiovascular risk factors would benefit patients with known (56.6%) and new atherosclerosis (33.5%) with suboptimal lipid control, (LDL > 70 in 42.2 and 34.9% respectively; LDL > 100 in 15.7 and 20.4%), and those not on high-intensity statin therapy (80 and 87.5%) or antiplatelet medications (13.2 and 50.6%). CUS is a low-yield diagnostic test in the evaluation of syncope, but it is useful in the diagnosis of atherosclerosis and identification of subjects who would benefit from optimal medical therapy. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

Reliability of Left Ventricular Hypertrophy by ECG Criteria in Children with Syncope: Do the Criteria Need to be Revised?

PubMed

Banerjee, Maalika M; Ramesh Iyer, V; Nandi, Deipanjan; Vetter, Victoria L; Banerjee, Anirban

2016-04-01

In the outpatient setting, children who present with syncope routinely undergo electrocardiograms (ECG). Because of concerns for hypertrophic cardiomyopathy, children with syncope meeting ECG criteria for left ventricular hypertrophy (LVH) will frequently undergo an echocardiogram. Our objectives were to determine whether Davignon criteria for ECG waves overestimate LVH in children presenting with syncope, and to study the usefulness of echocardiography in these children. We hypothesize that the Davignon criteria presently used for interpretation of ECGs overestimate LVH, resulting in unnecessary echocardiography in this clinical setting. The clinical database of The Children's Hospital of Philadelphia was evaluated from 2002 to 2012 to identify children between 9 and 16 years of age, who presented with non-exercise-induced, isolated syncope. From this group of patients, only those with clear-cut evidence of LVH (by Davignon criteria), who also underwent an echocardiogram, were selected. A total of 136 children with syncope were identified as having LVH by Davignon ECG criteria. None of these patients manifested any evidence of hypertrophic cardiomyopathy, with normal ventricular septum (average Z-score -0.68 ± 0.84), LV posterior wall (average Z-score -0.66 ± 1.18) and LV mass (average Z-score 0.52 ± 1.29). No significant correlation was found between summed RV6 plus SV1 and LV mass. Correlations between additional ECG parameters and measures of LVH by echocardiography were similarly poor. In children presenting with syncope and LVH by ECG, there was no evidence of true LVH by echocardiography. We propose that the Davignon ECG criteria for interpreting LVH in children overestimate the degree of hypertrophy in these children and the yield of echocardiography is extremely low.

A hairy fall: syncope resulting from topical application of minoxidil.

PubMed

Dubrey, S W; VanGriethuysen, J; Edwards, C M B

2015-09-07

We describe the case of a young man who developed syncope after using a high strength formulation of topical minoxidil as a hair growth restorer. Other potential cardiovascular and endocrine causes were excluded, and his symptoms resolved on discontinuation of the product. While syncope is a recognised side effect of using this powerful systemic antihypertensive agent, few cases are documented in the literature, which we illustrate in our discussion. 2015 BMJ Publishing Group Ltd.

Angiotensin-converting enzyme gene polymorphism in arrhythmogenic right ventricular dysplasia: is DD genotype helpful in predicting syncope risk?

PubMed

Ozben, Beste; Altun, Ibrahim; Sabri Hancer, Veysel; Bilge, Ahmet Kaya; Tanrikulu, Azra Meryem; Diz-Kucukkaya, Reyhan; Fak, Ali Serdar; Yilmaz, Ercument; Adalet, Kamil

2008-12-01

Arrhythmogenic right ventricular dysplasia (ARVD) is a heritable disorder characterised by fibrofatty replacement of right ventricular myocytes and increased risk of ventricular arrhythmias and sudden cardiac death. Angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism affects myocardial ACE levels. DD genotype favours myocardial fibrosis and is associated with malignant ventricular tachycardia. The aim of this study was to explore ACE gene polymorphism in ARVD patients. Twenty-nine patients with ARVD and 24 controls were included. All ARVD patients had documented sustained ventricular tachycardia. Thirteen patients had syncopal episodes. Six patients were resuscitated from sudden cardiac death. ACE gene polymorphism was identified by polymerase chain reaction technique. There was no significant difference in DD genotype frequency between ARVD patients and controls (44.8% vs. 45.8%, p=0.94). However, DD genotype frequency was significantly higher in ARVD patients with syncopal episodes compared to those without syncope (69.2% vs. 25.0%, p=0.017, odds ratio:6.750, 95% confidence interval: 1.318-34.565). DD genotype was detected in higher frequency also in patients with a family history of sudden cardiac death (66.7% vs. 39.1%,p=0.36). High prevalence of DD genotype in ARVD patients with syncope suggests that ACE I/D polymorphism might be useful in identifying high-risk patients for syncope.

Assessment of the QT interval in the electroencephalography (EEG) of children with syncope, epilepsy, and attention-deficit hyperactivity disorder (ADHD).

PubMed

Jha, Om P; Khurana, Divya S; Carvalho, Karen S; Melvin, Joseph J; Legido, Agustin; O'Riordan, Anna C; Valencia, Ignacio

2010-03-01

The interpretation of QT interval is often neglected during electroencephalography (EEG) reading. We compared the incidence of prolonged QT interval, as seen in the electrocardiography (ECG) recording lead of the EEG, in children presenting with seizure, syncope, or attention-deficit hyperactivity disorder (ADHD). Abnormal QT was defined as >460 ms. The incidence of prolonged QT in the seizure, syncope, and ADHD groups was 1/50 (2%), 7/50 (14%), and 2/50 (4%), respectively (P = .036, chi-square). The mean +/- SD of QT were 405 +/- 34, 424 +/- 39, and 414 +/- 36, respectively (P = .035, analysis of variance [ANOVA], syncope group, compared with seizure group). The incidence of prolonged QT as measured in the EEG was unexpectedly high in children presenting with seizure, syncope, or ADHD. These data support the concept that QT evaluation should be emphasized during routine EEG reading, as it may aid in identifying cases of undiagnosed cardiac conduction abnormalities. Prospective studies comparing EEG-ECG tracings with 12-lead ECG are warranted.

Case report of precursor B-cell lymphoblastic lymphoma presenting as syncope and cardiac mass in a nonimmunocompromised child.

PubMed

Hahn, Barry; Rao, Sudha; Shah, Binita

2007-08-01

We report the case of a previously healthy, 10-year-old boy who presented to the emergency department with a syncopal episode. In the emergency department, the patient was diagnosed with a right atrial mass, later identified as a precursor B-cell lymphoblastic lymphoma (LL). Most causes of syncope in children are not life threatening. In most cases, it indicates a predisposition to vasovagal episodes. Lymphomas account for approximately 7% of malignancies among children younger than 20 years, are more common in white males and immunocompromised patients, and are predominantly tumors of T-cell origin. Children with non-Hodgkin lymphoma usually present with extranodal disease, most frequently involving the abdomen (31%), mediastinum (26%), or head and neck (29%). Our patient was unique in that he was a nonimmunocompromised, black boy, presenting with syncope in the setting of a large atrial mass identified as a precursor B-cell LL. To our knowledge, there are no reported cases of precursor B-cell LL presenting as syncope and a cardiac mass.

Syncope (Fainting)

MedlinePlus

... due to sudden changes in body position, can trigger syncope. It’s important to determine the cause of ... and heart rate malfunctions in response to a trigger, such as emotional stress or pain. NMS typically ...

Malignant vasovagal syndrome in two patients with Wolff-Parkinson-White syndrome

PubMed Central

Gandhi, N M; Bennett, D H

2004-01-01

The presence of Wolff-Parkinson-White (WPW) syndrome in patients presenting with syncope suggests that tachyarrhythmia may be the cause. However, the symptoms require careful evaluation. Two young patients presented with syncope and were found to have WPW syndrome on their ECG. In both patients symptoms were suggestive of vasovagal syncope. During tilt testing, both the patients developed their typical symptoms with a fall in blood pressure and heart rate confirming the diagnosis of malignant vasovagal syndrome. PMID:15020537

Recurrent severe vomiting due to hyperthyroidism

PubMed Central

Chen, Li-ying; Zhou, Bo; Chen, Zhou-wen; Fang, Li-zheng

2010-01-01

Thyrotoxicosis may present in many ways; severe vomiting as a prominent symptom of thyrotoxicosis is uncommon. In this paper, we report a 24-year-old Chinese male with hyperthyroidism who presented with recurrent severe vomiting. The patient had had intermittent vomiting for seven years and had lost approximately 15 kg of weight. Gastroscopic examinations revealed chronic gastritis and one occasion peptic ulcer. He was treated with antacid and proton pump inhibitors, but his symptoms had no relief. His presenting symptoms suggested hyperthyroidism and were confirmed by laboratory data. After a month of propylthiouracil therapy, his symptoms were relieved. It should be noted that hyperthyroidism patients can have unexplained vomiting, and that hyperthyroidism may coexist with peptic ulcer in rare cases. Awareness of such atypical presentations of hyperthyroidism may help to make a correct diagnosis. PMID:20205308

Case Report: Recurrent severe vomiting due to hyperthyroidism.

PubMed

Chen, Li-ying; Zhou, Bo; Chen, Zhou-wen; Fang, Li-zheng

2010-03-01

Thyrotoxicosis may present in many ways; severe vomiting as a prominent symptom of thyrotoxicosis is uncommon. In this paper, we report a 24-year-old Chinese male with hyperthyroidism who presented with recurrent severe vomiting. The patient had had intermittent vomiting for seven years and had lost approximately 15 kg of weight. Gastroscopic examinations revealed chronic gastritis and one occasion peptic ulcer. He was treated with antacid and proton pump inhibitors, but his symptoms had no relief. His presenting symptoms suggested hyperthyroidism and were confirmed by laboratory data. After a month of propylthiouracil therapy, his symptoms were relieved. It should be noted that hyperthyroidism patients can have unexplained vomiting, and that hyperthyroidism may coexist with peptic ulcer in rare cases. Awareness of such atypical presentations of hyperthyroidism may help to make a correct diagnosis.

Serum levels of folate and cobalamin in women with recurrent spontaneous abortion.

PubMed

Sütterlin, M; Bussen, S; Ruppert, D; Steck, T

1997-10-01

We evaluated the folate and cobalamin status in 29 non-pregnant women with a history of recurrent spontaneous abortion (three or more consecutive) of unknown aetiology in comparison to 29 healthy nulligravidae of similar reproductive age (controls). Serum concentrations of folate and cobalamin showed no significant differences between the two groups. No correlation between age and vitamin concentrations was found. In the study group there was a significant negative correlation of the number of previous abortions and the concentration of serum folate. Patients with at least four previous miscarriages had significantly lower serum values of folic acid than women with three abortions, but not than controls. The underlying cause of this finding remains unclear. In conclusion, the serum concentrations of folic acid and vitamin B12 are not significantly altered in women with unexplained recurrent spontaneous abortions, and an association between a deficiency of these vitamins and an increased risk of pregnancy loss appears to be questionable in the majority of gestations.

Recurrent pulmonary embolism due to hydatid disease of heart. Study of 3 cases, one with intermittent tricuspid valve obstruction (atrial pseudomyxoma).

PubMed Central

Gilsanz, V; Campo, C; Cue, R; Estella, J; Estrada, R V; Perez-oteiza, C; Rabago, G; Rebollar, J L; Zarco, P

1977-01-01

Three cases of pulmonary hypertension caused by hydatid emboli from the right side of the heart are described; cardiac catheterisation was performed in 2. One case was confirmed at operation and 2 at necropsy. The pulmonary emboli were caused by hydatid vesicles in all 3 cases and in none was there pulmonary thrombosis; free scolices were found in the pulmonary alveoli in 2. In 1 patient with repeated syncopal attacks there was a pedunculated cyst in the right atrium which was though to have intermittently obstructed the tricuspid valve. Gamma radiography, angiocardiography, and necropsy suggested a mechanical cause for the pulmonary hypertenion with no vasoconstrictive element. The surgical patient was alive and well 18 months later. Images PMID:861098

Fainting (Syncope)

MedlinePlus

... Attack Heart Valve Problems Join our e-newsletter! Aging & Health A to Z Fainting (Syncope) Basic Facts & ... November 2016 Posted: March 2012 © 2018 Health in Aging. All rights reserved. Feedback • Site Map • Privacy Policy • ...

School Nurses on the Front Lines of Medicine: The Approach to a Student After a Syncopal Event: Don't "PASS OUT".

PubMed

Hackett, Gretchen; Brady, Jodi; Olympia, Robert P

2018-03-01

Students presenting with syncope and/or seizure occur occasionally in the school setting. Several studies have shown that seizures as well as respiratory distress are the most common medical emergencies that prompt school nurses and staff to contact emergency medical services (EMS) to transport students to the closest emergency department (Knight 1999, Olympia 2005). It is important to develop a differential diagnosis for syncope, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow-up at their primary health care provider's office, or directly to the closest emergency department via EMS). This article describes the initial assessment and management of two students presenting after syncopal events.

Case report of vasovagal syncope associated with single pulse transcranial magnetic stimulation in a healthy adult participant.

PubMed

Gillick, Bernadette T; Rich, Tonya; Chen, Mo; Meekins, Gregg D

2015-12-01

Non-invasive brain stimulation-related seizures or syncopal events are rare. However, we report on a syncopal event in a healthy female during a transcranial magnetic stimulation single-pulse testing session. A 47-year-old healthy female presented for a transcranial magnetic stimulation session involving single-pulse assessment of cortical excitability. During the session, the participant appeared to have a brief event involving fainting and myoclonic jerks of the upper extremities. Orthostatic assessment was performed after the event and physician evaluation determined that this was a vasovagal syncopal event. The ethical aspects of this neurophysiology testing protocol were reviewed by the University of Minnesota Institutional Review Board (IRB), and formal IRB approval was deemed unnecessary for single-pulse assessment of healthy control participants not directly involved in a research study. Informed consent was obtained by the participant, including review of potential adverse events. Although rare and rarely reported, vasovagal syncopal events surrounding non-invasive brain stimulation do occur. Thorough pre-screening should incorporate assessment of history of syncope and a plan for risk mitigation if such an event should occur. A complete assessment of the impact of stimulation on the autonomic nervous system is unknown. As such studies expand into patients with myriad neurologic diagnoses, further studies on this effect, in both healthy control and patient populations, are warranted. Such knowledge could contribute to identification of the optimal study participant, and improvements in techniques of stimulation administration.

"Cardio-Neuromodulation" With a Multielectrode Irrigated Catheter: A Potential New Approach for Patients With Cardio-Inhibitory Syncope.

PubMed

Debruyne, Philippe

2016-09-01

Syncope is frequently neurally mediated and can seriously affect quality of life. Different ablation strategies have been successfully performed. These approaches have not gained wide acceptance and are quite extensive and complex, exposing patients to significant risks. This article reports the case of a 16-year-old girl who was severely affected by frequent and prolonged episodes of syncope and was treated by tailored ablation of the anterior right ganglionated plexus with a multielectrode irrigated catheter. She had fainted >30 times in the 5 years preceding treatment, experiencing approximately 10 severe episodes of syncope in the previous 12 months. After 3 minutes of ablation, the P-P interval was reduced by >400 milliseconds. Syncope disappeared and the patient has remained completely asymptomatic over a follow-up of 22 months. The "reset" basal P-P interval has remained unchanged (follow-up electrocardiogram at 16 months). At 6 months, there was no residual heart rate activity <50 bpm. On 24-hour rhythm registration, P-P intervals ≥1,000 milliseconds (corresponding to a heart rate of ≤60 bpm) were reduced by >16,000 beats. We believe that this case report is original for several reasons: the unusual clinical presentation; the unique structure targeted; the very limited ablation, implying much lower risks for the patient; the anatomical approach; and the different endpoint. This new "cardio-neuromodulation" approach could be useful for the treatment of patients with neurally mediated syncope. © 2016 Wiley Periodicals, Inc.

Unexplained illness among Persian Gulf War veterans in an Air National Guard Unit: preliminary report--August 1990-March 1995.

PubMed

1995-06-16

In November 1994, the U.S. Department of Veterans' Affairs (VA), the Department of Defense (DoD), and the Pennsylvania Department of Health requested that CDC investigate a report of unexplained illnesses among members of an Air National Guard (ANG) unit in south-central Pennsylvania (Unit A) who were veterans of the Persian Gulf War (PGW) (August 1990-June 1991). These veterans had been evaluated at a local VA medical center for symptoms that included recurrent rash, diarrhea, and fatigue. A three-stage investigation was planned to 1) verify and characterize signs and symptoms in PGW veterans attending the VA medical center; 2) determine whether the prevalence of symptoms was higher among members of Unit A than among members of other units deployed to the PGW and, if so, whether the increased prevalence was associated with PGW deployment; and 3) characterize the illness and identify associated risk factors. This report presents preliminary findings from stages 1 and 2 (stage 3 is in progress).

What factors influence parents' perception of the quality of life of children and adolescents with neurocardiogenic syncope?

PubMed

Grimaldi Capitello, Teresa; Fiorilli, Caterina; Placidi, Silvia; Vallone, Roberta; Drago, Fabrizio; Gentile, Simonetta

2016-05-17

Health-related quality of life, which can be investigated using self-reports or parental reports, could help healthcare providers understand the subjective perception of well-being of children suffering from recurrent syncopal episodes. Quality of life is not only a measure of health but is also a reflection of patients' and parents' perceptions and expectations of health. This study assessed: 1) the consistency and agreement between pediatric patients' self-reports and parents' proxy-reports of their child's quality of life; 2) whether this patient-parent agreement is dependent on additional demographic and clinical or distress factors; 3) whether the parents' psychological distress influences children's and parents' responses to questionnaires on quality of life. One hundred and twenty-five Italian children aged 6-18 years old (Mean age 12.75, SD 2.73, 48 % female) and their parents completed the Pediatric Quality of Life inventory with self-reports and parent-proxy reports, the Parenting Stress Index - Short Form questionnaire and the Child Behavior Checklist for ages 6-18. Patients' and parents' scores on quality of life were analyzed via an intra-class correlation coefficient, Spearman's correlation coefficient, Wilcoxon signed-rank test, and Bland-Altman plot. Child-rated quality of life was lower than parent-rated quality of life. However, there were no statistically significant differences between pediatric patients' self-reports and their parents' proxy-reports of on quality of life. Clinically significant patient-parent variation in pediatric health-related quality of life was observed. Differences in patient-parent proxy Pediatric Quality of Life inventory Total Scale Score scores were significantly associated with patient age. Concerning parents' proxy-ratings of their children's quality of life on the Pediatric Quality of Life inventory, parental stress was found to be negatively associated with their perceptions of their child's psychological quality of life. Indeed, childhood illness is a source of stress for the whole family, and exposes family members to a greater risk of developing psychosocial difficulties. In conclusion, this study invites reflection on the use of cross-informants in investigating the quality of life of young patients with neurocardiogenic syncope and the psychological factors that influence how quality of life is perceived.

The cannabis hyperemesis syndrome characterized by persistent nausea and vomiting, abdominal pain, and compulsive bathing associated with chronic marijuana use: a report of eight cases in the United States.

PubMed

Soriano-Co, Maria; Batke, Mihaela; Cappell, Mitchell S

2010-11-01

The cannabis hyperemesis syndrome, which is associated with chronic cannabis use, was recently reported in seven case reports and one clinical series of ten patients from Australia. We further characterize this syndrome with eight well-documented cases in the United States and report results of cannabis discontinuation and cannabis rechallenge. Patients were identified by the three investigators in gastroenterology clinic or inpatient wards at William Beaumont Hospital from January to August 2009 based on chronic cannabis use; otherwise unexplained refractory, recurrent vomiting; and compulsive bathing. Charts were retrospectively analyzed with follow-up data obtained from subsequent physician visits and patient interviews. The eight patients on average were 32.4 ± 4.1 years old. Five were male. The mean interval between the onset of cannabis use and development of recurrent vomiting was 19.0 ± 3.7 years. Patients had a mean of 7.1 ± 4.3 emergency room visits, 5.0 ± 2.7 clinic visits, and 3.1 ± 1.9 admissions for this syndrome. All patients had visited at least one other hospital in addition to Beaumont Hospital. All patients had vomiting (mean vomiting episodes every 3.0 ± 1.7 h), compulsive bathing (mean = 5.0 ± 2.0 baths or showers/day; mean total bathing time = 5.0 ± 5.1 h/day), and abdominal pain. Seven patients took hot baths or showers, and seven patients experienced polydipsia. Four out of five patients who discontinued cannabis use recovered from the syndrome, while the other three patients who continued cannabis use, despite recommendations for cessation, continued to have this syndrome. Among those four who recovered, one patient had recurrence of vomiting and compulsive bathing with cannabis resumption. Cannabis hyperemesis is characterized by otherwise unexplained recurrent nausea and vomiting, compulsive bathing, abdominal pain, and polydipsia associated with chronic cannabis use. This syndrome can occur in the United States as well as in Australia. Cannabis cessation may result in complete symptomatic recovery.

Novel genes and mutations in patients affected by recurrent pregnancy loss.

PubMed

Quintero-Ronderos, Paula; Mercier, Eric; Fukuda, Michiko; González, Ronald; Suárez, Carlos Fernando; Patarroyo, Manuel Alfonso; Vaiman, Daniel; Gris, Jean-Christophe; Laissue, Paul

2017-01-01

Recurrent pregnancy loss is a frequently occurring human infertility-related disease affecting ~1% of women. It has been estimated that the cause remains unexplained in >50% cases which strongly suggests that genetic factors may contribute towards the phenotype. Concerning its molecular aetiology numerous studies have had limited success in identifying the disease's genetic causes. This might have been due to the fact that hundreds of genes are involved in each physiological step necessary for guaranteeing reproductive success in mammals. In such scenario, next generation sequencing provides a potentially interesting tool for research into recurrent pregnancy loss causative mutations. The present study involved whole-exome sequencing and an innovative bioinformatics analysis, for the first time, in 49 unrelated women affected by recurrent pregnancy loss. We identified 27 coding variants (22 genes) potentially related to the phenotype (41% of patients). The affected genes, which were enriched by potentially deleterious sequence variants, belonged to distinct molecular cascades playing key roles in implantation/pregnancy biology. Using a quantum chemical approach method we established that mutations in MMP-10 and FGA proteins led to substantial energetic modifications suggesting an impact on their functions and/or stability. The next generation sequencing and bioinformatics approaches presented here represent an efficient way to find mutations, having potentially moderate/strong functional effects, associated with recurrent pregnancy loss aetiology. We consider that some of these variants (and genes) represent probable future biomarkers for recurrent pregnancy loss.

Recurrent unexplained palpitations (RUP) study comparison of implantable loop recorder versus conventional diagnostic strategy.

PubMed

Giada, Franco; Gulizia, Michele; Francese, Maura; Croci, Francesco; Santangelo, Lucio; Santomauro, Maurizio; Occhetta, Eraldo; Menozzi, Carlo; Raviele, Antonio

2007-05-15

The aim of the study was to compare the diagnostic yield and the costs of implantable loop recorder (ILR) with those of the conventional strategy in patients with unexplained palpitations. In patients with unexplained palpitations, especially in those with infrequent symptoms, the conventional strategy, including short-term ambulatory electrocardiogram (ECG) monitoring and electrophysiological study, sometimes fails to establish a diagnosis. We studied 50 patients with infrequent (< or =1 episode/month), sustained (>1 min) palpitations. Before enrollment, patients had a negative initial evaluation, including history, physical examination, and ECG. Patients were randomized either to conventional strategy (24-h Holter recording, a 4-week period of ambulatory ECG monitoring with an external recorder, and electrophysiological study) (n = 24) or to ILR implantation with 1-year monitoring (n = 26). Hospital costs of the 2 strategies were calculated. A diagnosis was obtained in 5 patients in the conventional strategy group, and in 19 subjects in the ILR group (21% vs. 73%, p < 0.001). Despite the higher initial cost, the cost per diagnosis in the ILR group was lower than in the conventional strategy group (euro 3,056 +/- euro 363 vs. euro 6,768 +/- euro 6,672, p = 0.012). In subjects without severe heart disease and with infrequent palpitations, ILR is a safe and more cost-effective diagnostic approach than conventional strategy.

Does Deep Bradycardia Increase the Risk of Arrhythmias and Syncope in Endurance Athletes?

PubMed

Matelot, D; Schnell, F; Khodor, N; Endjah, N; Kervio, G; Carrault, G; Thillaye du Boullay, N; Carre, F

2016-09-01

The aim of this study was to evaluate whether endurance athletes who exhibit deep bradycardia are more prone to arrhythmias and reflex syncope than their non-bradycardic peers. 46 healthy men (ages 19-35) were divided into 3 groups based on whether they were sedentary (SED,<2 h/week) or endurance trained (ET,>6 h/week), and non-bradycardic (NB, resting heart rate (HR)≥60 bpm) or bradycardic (B, resting HR<50 bpm). Resting HR was lower in ETB vs. ETNB and SED (43.8±3.1, 61.3±3.3, 66.1±5.9 bpm, respectively; p<0.001). Thus, 16 SED, 13 ETNB and 17 ETB underwent resting echocardiography, maximal exercise test, tilt test (TT) and 24 h-Holter ECG. Subjects were followed-up during 4.7±1.1 years for training, syncope and cardiac events. Our results showed that incidence of arrhythmias and hypotensive susceptibility did not differ between groups. During follow-up, no episode of syncope or near-syncope was reported. However, cardio-inhibitory syncope occurrence tended to be higher in ETB. Left ventricular end-diastolic diameter index was increased in ETB vs. ETNB and was correlated with resting HR (r=- 0.64; p<0.001). As a result, athletes with deep bradycardia do not present more arrhythmias and more hypotensive susceptibility than their non-bradycardic peers. Cardiac enlargement and autonomic alteration both seem to be involved in an athlete's bradycardia. © Georg Thieme Verlag KG Stuttgart · New York.

Clinical factors associated with classical symptoms of aortic valve stenosis.

PubMed

Nishizaki, Yuji; Daimon, Masao; Miyazaki, Sakiko; Suzuki, Hiromasa; Kawata, Takayuki; Miyauchi, Katsumi; Chiang, Shuo-Ju; Makinae, Haruka; Shinozaki, Tomohiro; Daida, Hiroyuki

2013-05-01

The recognition of clinical symptoms is critical to a therapeutic strategy for aortic valve stenosis (AS). It was hypothesized that AS symptoms might have multiple causes; hence, a study was conducted to investigate the factors that separately influence the classic symptoms of dyspnea, angina and syncope in AS. The medical records of 170 consecutive patients with AS (> or = moderate grade) were reviewed. A multivariate logistic regression analysis was used to evaluate the hemodynamic and clinical factors that separately influence the development of three clinical symptoms: dyspnea (defined as NYHA class > or = 2), angina, and syncope. The most common symptom was dyspnea (47.1%), followed by angina (12.4%) and syncope (4.7%). The factors associated with dyspnea were a higher e' ratio (p = 0.04) and peak aortic valve velocity (p = 0.01). Only the severity of AS was associated with syncope. The presence of hypertension was associated with angina (p = 0.04). Moreover, coronary angiography was performed in 59 patients before aortic valve replacement and revealed coronary stenosis (> 50% diameter stenosis) in 11/16 patients (69%) that had angina. The presence of coronary stenosis was significantly associated with angina (p = 0.02). The development of dyspnea, angina or syncope was influenced by different factors in AS. Dyspnea and syncope were mainly associated with AS severity, and diastolic dysfunction also influenced dyspnea. In contrast, angina was mainly related to the presence of coronary stenosis rather than to AS severity. These factors should be considered when, selecting a therapeutic strategy for AS patients in the modern era.

Treatment for Syncope

MedlinePlus

... When it comes to treatment, there is no "one size fits all" approach, making an accurate diagnosis very important. Treatment should address the underlying cause of syncope . Depending on the diagnosis, ... or controlled with one or more of the following therapies: Simple reassurance, ...

Vasovagal Syncope

MedlinePlus

... Combined, the drop in blood pressure and slowed heart rate quickly reduce blood flow to your brain, and you faint. Sometimes there is no classical vasovagal syncope trigger, but common triggers include: Standing for long periods of time Heat exposure Seeing blood Having blood drawn Fear of ...

Hereditary sensory and autonomic neuropathy type IV and orthopaedic complications.

PubMed

Kim, W; Guinot, A; Marleix, S; Chapuis, M; Fraisse, B; Violas, P

2013-11-01

Hereditary sensory and autonomic neuropathy type IV (HSAN-IV) is a very rare autosomal recessive disorder characterized by recurrent episodes of unexplained fever, extensive anhidrosis, total insensitivity to pain, hypotonia, and mental retardation. The most frequent complications of this disease are corneal scarring, multiple fractures, joint deformities, osteomyelitis, and disabling self-mutilations. We reported the case of a 12-year-old boy. The goal was to discuss our decision-making and compare this case with cases described in the literature. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

[Recurrent spontaneous miscarriages and hyperhomocysteinemia].

PubMed

Del Bianco, A; Maruotti, G; Fulgieri, A M; Celeste, T; Lombardi, L; Amato, N A; Pietropaolo, F

2004-10-01

Recurrent fetal loss is defined as the number of consecutive miscarriages which is not less than 2 occurred within the 16th week of gestation and it is a very interesting pathology of pregnancy. Further to thrombophilia, very important causes have been identified, since the damage of the vascular system supporting the placenta may cause a deficiency of placenta functions and development, leading to a loss of the conception product, also in a condition of hyperhomocystinemia, causing a damage to the vascular endothelium. Hyperhomocystinemia seems to be a risk factor for artero-venous thrombotic diseases, even not in pregnancy. We have examined 40 patients referred to our Institute for unexplained fetal loss (at least 2 consecutive miscarriages within the 16th week of gestation) and the same number of patients who had at least 1 spontaneous delivery with a healthy and alive newborn and none abortion nor fetal death nor abruptio placentae. The mean levels of homocystinemia observed were significantly different in the 2 groups (p = or < 0.05). In the control group the values of plasmatic homocysteine were 10+/-4 micromol/L, corresponding to normal range, while in the other group the values of plasmatic homocysteine were 21+/-6 micromol/L, values certainly elevated, also because during the 1st trimester of pregnancy the levels of homocysteine decrease, reaching the lowest value during the 2nd trimester of pregnancy. In particular, high levels of homocysteine have been found in 25% (10) of women with unexplained early fetal loss. Hypercystinemia, as a consequence of an interaction between a primary genetic defect and a nutrition condition (folate deficiency), may be a cause of recurrent miscarriages. Therefore, in these cases, a possible hypercystinemia should be searched and an association of folic acid and vitamin B6, a non teratogenic treatment, should be useful to restore the metabolic picture and to favour the pregnancy outcome.

Recurrent Coding Sequence Variation Explains Only A Small Fraction of the Genetic Architecture of Colorectal Cancer

PubMed Central

Timofeeva, Maria N.; Kinnersley, Ben; Farrington, Susan M.; Whiffin, Nicola; Palles, Claire; Svinti, Victoria; Lloyd, Amy; Gorman, Maggie; Ooi, Li-Yin; Hosking, Fay; Barclay, Ella; Zgaga, Lina; Dobbins, Sara; Martin, Lynn; Theodoratou, Evropi; Broderick, Peter; Tenesa, Albert; Smillie, Claire; Grimes, Graeme; Hayward, Caroline; Campbell, Archie; Porteous, David; Deary, Ian J.; Harris, Sarah E.; Northwood, Emma L.; Barrett, Jennifer H.; Smith, Gillian; Wolf, Roland; Forman, David; Morreau, Hans; Ruano, Dina; Tops, Carli; Wijnen, Juul; Schrumpf, Melanie; Boot, Arnoud; Vasen, Hans F A; Hes, Frederik J.; van Wezel, Tom; Franke, Andre; Lieb, Wolgang; Schafmayer, Clemens; Hampe, Jochen; Buch, Stephan; Propping, Peter; Hemminki, Kari; Försti, Asta; Westers, Helga; Hofstra, Robert; Pinheiro, Manuela; Pinto, Carla; Teixeira, Manuel; Ruiz-Ponte, Clara; Fernández-Rozadilla, Ceres; Carracedo, Angel; Castells, Antoni; Castellví-Bel, Sergi; Campbell, Harry; Bishop, D. Timothy; Tomlinson, Ian P M; Dunlop, Malcolm G.; Houlston, Richard S.

2015-01-01

Whilst common genetic variation in many non-coding genomic regulatory regions are known to impart risk of colorectal cancer (CRC), much of the heritability of CRC remains unexplained. To examine the role of recurrent coding sequence variation in CRC aetiology, we genotyped 12,638 CRCs cases and 29,045 controls from six European populations. Single-variant analysis identified a coding variant (rs3184504) in SH2B3 (12q24) associated with CRC risk (OR = 1.08, P = 3.9 × 10−7), and novel damaging coding variants in 3 genes previously tagged by GWAS efforts; rs16888728 (8q24) in UTP23 (OR = 1.15, P = 1.4 × 10−7); rs6580742 and rs12303082 (12q13) in FAM186A (OR = 1.11, P = 1.2 × 10−7 and OR = 1.09, P = 7.4 × 10−8); rs1129406 (12q13) in ATF1 (OR = 1.11, P = 8.3 × 10−9), all reaching exome-wide significance levels. Gene based tests identified associations between CRC and PCDHGA genes (P < 2.90 × 10−6). We found an excess of rare, damaging variants in base-excision (P = 2.4 × 10−4) and DNA mismatch repair genes (P = 6.1 × 10−4) consistent with a recessive mode of inheritance. This study comprehensively explores the contribution of coding sequence variation to CRC risk, identifying associations with coding variation in 4 genes and PCDHG gene cluster and several candidate recessive alleles. However, these findings suggest that recurrent, low-frequency coding variants account for a minority of the unexplained heritability of CRC. PMID:26553438

DYZ1 copy number variation, Y chromosome polymorphism and early recurrent spontaneous abortion/early embryo growth arrest.

PubMed

Yan, Junhao; Fan, Lingling; Zhao, Yueran; You, Li; Wang, Laicheng; Zhao, Han; Li, Yuan; Chen, Zi-Jiang

2011-12-01

To find the association between recurrent spontaneous abortion (RSA)/early embryo growth arrest and Y chromosome polymorphism. Peripheral blood samples of the male patients of big Y chromosome, small Y chromosome and other male patients whose partners suffered from unexplained RSA/early embryo growth arrest were collected. PCR and real-time fluorescent quantitative PCR were used to test the deletion and the copy number variation of DYZ1 region in Y chromosome of the patients. A total of 79 big Y chromosome patients (48 of whose partners suffered from RSA or early embryo growth arrest), 7 small Y chromosome patients, 106 other male patients whose partners had suffered from unexplained RSA or early embryo growth arrest, and 100 normal male controls were enrolled. There was no fraction deletion of DYZ1 detected both in big Y patients and in normal men. Of RSA patients, 1 case showed deletion of 266bp from the gene locus 25-290bp, and 2 cases showed deletion of 773bp from 1347 to 2119bp. Of only 7 small Y chromosome patients, 2 cases showed deletion of 266bp from 25 to 290bp, and 4 cases showed deletion of 773bp from 1347 to 2119bp and 275bp from 3128 to 3420bp. The mean of DYZ1 copies was 3900 in normal control men; the mean in big Y patients was 5571, in RSA patients was 2655, and in small Y patients was 1059. All of the others were significantly different (P<0.01) compared with normal control men, which meant that DYZ1 copy number in normal control men was less than that of big Y chromosome patients, and was more than that of unexplained early RSA patients and small Y patients. The integrity and copy number variation of DYZ1 are closely related to the Y chromosome length under microscope. The cause of RSA/early embryo growth arrest in some couples may be the increase (big Y patients) or decrease of DYZ1 copy number in the husbands' Y chromosome. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Stroke mimic diagnoses presenting to a hyperacute stroke unit.

PubMed

Dawson, Ang; Cloud, Geoffrey C; Pereira, Anthony C; Moynihan, Barry J

2016-10-01

Stroke services have been centralised in several countries in recent years. Diagnosing acute stroke is challenging and a high proportion of patients admitted to stroke units are diagnosed as a non-stroke condition (stroke mimics). This study aims to describe the stroke mimic patient group, including their impact on stroke services. We analysed routine clinical data from 2,305 consecutive admissions to a stroke unit at St George's Hospital, London. Mimic groupings were derived from 335 individual codes into 17 groupings. From 2,305 admissions, 555 stroke mimic diagnoses were identified (24.2%) and 72% of stroke mimics had at least one stroke risk factor. Common mimic diagnoses were headache, seizure and syncope. Medically unexplained symptoms and decompensation of underlying conditions were also common. Median length of stay was 1 day; a diagnosis of dementia (p=0.028) or needing MRI (p=0.006) was associated with a longer stay. Despite emergency department assessment by specialist clinicians and computed tomography brain, one in four suspected stroke patients admitted to hospital had a non-stroke diagnosis. Stroke mimics represent a heterogeneous patient group with significant impacts on stroke services. Co-location of stroke and acute neurology services may offer advantages where service reorganisation is being considered. © Royal College of Physicians 2016. All rights reserved.

Essential Hypotension and Allostasis Registry

ClinicalTrials.gov

2018-03-30

Blood Pressure; Depression; Panic Attack; Fibromyalgia; POTS; Inappropriate Sinus Tachycardia; Coronary Heart Disease; Acute Coronary Syndrome (ACS); Acute Myocardial Infarction (AMI); Cerebrovascular Disease (CVD); Transient Ischemic Attack (TIA); Atrial Fibrillation; Diabetes Mellitus; Cancer; Systolic Heart Failure; Diastolic Heart Failure; Chronic Fatigue Syndrome; Syncope; Vasovagal Syncope

Reninoma presenting as cardiac syncope

PubMed Central

Tak, Shahid I; Wani, Mohd Lateef; Khan, Khursheed A; Alai, Mohd Sultan; Shera, Altaf Hussain; Ahangar, Abdul G; Khan, Yasir Bashir; Nayeem-ul-Hassan; Irshad, Ifat

2011-01-01

Reninoma, a renin-secreting tumor of the juxta-glomerular cells of the kidney, is a rare but surgically treatable cause of secondary hypertension in children. We report a case of reninoma presenting as cardiac syncope with long QTc on electrocardiogram due to hypokalemia. PMID:21677812

Role of brain natriuretic peptide (BNP) in risk stratification of adult syncope

PubMed Central

Reed, Matthew J; Newby, David E; Coull, Andrew J; Jacques, Keith G; Prescott, Robin J; Gray, Alasdair J

2007-01-01

Aims To assess the value of a near‐patient brain natriuretic peptide (BNP) test to predict medium term (3 month) serious outcome for adult syncope patients presenting to a UK emergency department (ED). Methods This was a prospective cohort pilot study. Consecutive patients aged ⩾16 years presenting with syncope over a 3 month period were eligible for prospective enrolment. All patients who were medium or high risk according to our ED's existing syncope guidelines underwent near‐patient BNP testing using the Triage point of care machine. Results 99 patients were recruited. 72 of 82 high and medium risk patients underwent BNP measurement. 11 patients had a serious outcome, 9 of whom had BNP measured. In 25 (35%) patients, BNP was ⩾100 pg/ml, and in 3 of these it was >1000 pg/ml. 6 of the 25 patients (24%) with a BNP >100 pg/ml, and all 3 patients with a BNP >1000 pg/ml, were in the serious outcome group. BNP was raised over 100 pg/ml in 6 of the 9 serious outcome patients having a BNP measured (66%), and over 1000 pg/ml in 3 (33%). Conclusions This early work suggests that BNP may have a role in the risk assessment of syncope patients in the ED. Further work is required to see how BNP interacts with other clinical variables. Near‐patient BNP testing may be shown to be an independent predictor of adverse outcome either alone or incorporated into existing syncope clinical decision rules and scores in order to improve their sensitivity and specificity. Further studies are required to evaluate this. PMID:17954830

Panic symptoms in transient loss of consciousness: Frequency and diagnostic value in psychogenic nonepileptic seizures, epilepsy and syncope.

PubMed

Rawlings, G H; Jamnadas-Khoda, J; Broadhurst, M; Grünewald, R A; Howell, S J; Koepp, M; Parry, S W; Sisodiya, S M; Walker, M C; Reuber, M

2017-05-01

Previous studies suggest that ictal panic symptoms are common in patients with psychogenic nonepileptic seizures (PNES). This study investigates the frequency of panic symptoms in PNES and if panic symptoms, just before or during episodes, can help distinguish PNES from the other common causes of transient loss of consciousness (TLOC), syncope and epilepsy. Patients with secure diagnoses of PNES (n=98), epilepsy (n=95) and syncope (n=100) were identified using clinical databases from three United Kingdom hospitals. Patients self-reported the frequency with which they experienced seven symptoms of panic disorder in association with their episodes. A composite panic symptom score was calculated on the basis of the frequency of symptoms. 8.2% of patients with PNES reported "never" experiencing any of the seven panic symptoms in their episodes of TLOC. Patients with PNES reported more frequent panic symptoms in their attacks than those with epilepsy (p<0.001) or syncope (p<0.001), however, patients with PNES were more likely "rarely" or "never" to report five of the seven-ictal panic symptoms than "frequently" or "always" (45-69% versus 13-29%). A receiver operating characteristic analysis demonstrated that the composite panic symptom score distinguished patients with PNES from the other groups (sensitivity 71.1%, specificity 71.2%), but not epilepsy from syncope. Patients with PNES report TLOC associated panic symptoms more commonly than those with epilepsy or syncope. Although panic symptoms are reported infrequently by most patients with PNES, a composite symptom score may contribute to the differentiation between PNES and the other two common causes of TLOC. Copyright © 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

[Renin-angiotensin-aldosterone system activity during head-up tilt testing in patients with vasovagal syncope].

PubMed

Gajek, Jacek; Zyśko, Dorota; Mazurek, Walentyna

2005-08-01

The stimulation of renin-angiotensin-aldosterone (RAA) system during tilt table test is caused by sympathetic nervous system activation by orthostatic stress and a serotonin release as well. In healthy individuals increase of plasma renin activity during test with maximal values on the peak of the test was described. The aim of the study was to assess the activation of RAAS in patients with neurally mediated syncope during the tilt table test by means of plasma renin activity and serum aldosterone levels. The study was carried out in 31 patients aged 39.4 +/- 15.0 years (18 women and 13 men) with neurally mediated syncope during tilt test. Plasma renin activity was assessed in the baseline conditions, immediately after the test and 10 minutes after the test using radioenzymatic assay. Aldosterone concentrations were measured radioimmunologically, twice: after 30 minutes supine rest and after the syncope. Plasma renin activity during supine rest was 2.2 +/- 2.4 ng/ml/h, rose after the syncope 2.5-fold to 5.2 +/- 4.5 ng/ml/h (p < 0.001 comparing to baseline) stayed on similar level approximately for the next 10 minutes--4.9 +/- 5.5 ng/ml/h (p = n.s.). In 11 patients (35%) 10 minutes after the test even further increase of PRA was observed. Serum aldosterone level increased significantly immediately after tilt test (90.0 +/- 72.9 vs 178.8 +/- 150.1 pg/ml, p < 0.01). Authors showed, that in patients with NMS plasma renin activity increases and this increase lasts for 10 minutes after the syncope and the concentration of aldosterone increases immediately after tilt test.

Comparison of corrected QT interval as measured on electroencephalography versus 12-lead electrocardiography in children with a history of syncope.

PubMed

Massey, Shavonne L; Wise, Marshall S; Madan, Nandini; Carvalho, Karen; Khurana, Divya; Legido, Agustin; Valencia, Ignacio

2011-11-01

Long QT syndrome can present with neurological manifestations, including syncope and seizure-like activity. These patients often receive an initial neurologic evaluation, including electroencephalography (EEG). Our previous retrospective study suggested an increased prevalence of prolonged corrected QT interval (QTc) measured during the EEG of patients with syncope. The aim of the current study is to assess the accuracy of the EEG QTc reading compared with the nonsimultaneous 12-lead electrocardiography (ECG) in children with syncope. Abnormal QTc was defined as ≥450 ms in boys, ≥460 ms in girls. Forty-two children were included. There was no significant correlation between QTc readings in the EEG and ECG. EEG failed to identify 2 children with prolonged QTc in the ECG and overestimated the QTc in 3 children with normal QTc in the ECG. This study suggests that interpretation of the QTc segment during an EEG is limited. Further studies with simultaneous EEG and 12-lead ECG are warranted.

[Role of the sympathetic nervous system in vasovagal syncope and rationale for beta-blockers and norepinephrine transporter inhibitors].

PubMed

Márquez, Manlio F; Gómez-Flores, Jorge Rafael; González-Hermosillo, Jesús A; Ruíz-Siller, Teresita de Jesús; Cárdenas, Manuel

2016-12-29

Vasovagal or neurocardiogenic syncope is a common clinical situation and, as with other entities associated with orthostatic intolerance, the underlying condition is a dysfunction of the autonomic nervous system. This article reviews various aspects of vasovagal syncope, including its relationship with orthostatic intolerance and the role of the autonomic nervous system in it. A brief history of the problem is given, as well as a description of how the names and associated concepts have evolved. The response of the sympathetic system to orthostatic stress, the physiology of the baroreflex system and the neurohumoral changes that occur with standing are analyzed. Evidence is presented of the involvement of the autonomic nervous system, including studies of heart rate variability, microneurography, cardiac innervation, and molecular genetic studies. Finally, we describe different studies on the use of beta-blockers and norepinephrine transporter inhibitors (sibutramine, reboxetine) and the rationality of their use to prevent this type of syncope. Creative Commons

Complexity Matching Effects in Bimanual and Interpersonal Syncopated Finger Tapping

PubMed Central

Coey, Charles A.; Washburn, Auriel; Hassebrock, Justin; Richardson, Michael J.

2016-01-01

The current study was designed to investigate complexity matching during syncopated behavioral coordination. Participants either tapped in (bimanual) syncopation using their two hands, or tapped in (interpersonal) syncopation with a partner, with each participant using one of their hands. The time series of inter-tap intervals (ITI) from each hand were submitted to fractal analysis, as well as to short-term and multi-timescale cross-correlation analyses. The results demonstrated that the fractal scaling of one hand’s ITI was strongly correlated to that of the other hand, and this complexity matching effect was stronger in the bimanual condition than in the interpersonal condition. Moreover, the degree of complexity matching was predicted by the strength of short-term cross-correlation and the stability of the asynchrony between the two tapping series. These results suggest that complexity matching is not specific to the inphase synchronization tasks used in past research, but is a general result of coordination between complex systems. PMID:26840612

Clinical utility of serum lactate levels for differential diagnosis of generalized tonic-clonic seizures from psychogenic nonepileptic seizures and syncope.

PubMed

Doğan, Ebru Apaydın; Ünal, Ali; Ünal, Aslıhan; Erdoğan, Çağla

2017-10-01

The differential diagnosis of generalized tonic-clonic seizures (GTCS), psychogenic nonepileptic seizures (PNES), and syncope constitutes a major challenge. Misdiagnosis rates up to 20 to 30% are reported in the literature. To assess the clinical utility of serum lactate levels for differentiation of GTCS, PNES, and syncope based on gender differences. Data from 270 patients were evaluated retrospectively. Only patients ≥18 years old with the final diagnosis of GTCS, PNES, or syncope in their chart were recruited. Serum lactate levels were measured in the first 2h of the index event. Serum lactate levels in patients with GTCS (n=157) were significantly higher than in the patients with PNES (n=25) (p<0.001) and syncope (n=88) (p<0.001). When compared with the females, serum lactate levels in patients with GTCS were significantly higher in the male subgroup (p=0.004). In male patients the ROC analysis yielded a serum lactate value of 2.43mmol/l with a sensitivity of 0.85 and a specificity of 0.88 as the optimal cut-off value to distinguish GTCS from other events. The ROC analysis for the AUC yielded a high estimate of 0.94 (95% confidence interval: 0.91-0.98). When a cut-off value of 2.43mmol/l was chosen for the females, which was an optimal value for male patients, the specificity was 0.85, however, the sensitivity was 0.64. We propose that serum lactate level when measured in the first 2h after the index event has a high clinical utility in the differential diagnosis of GTCS, PNES, and syncope. With concomitant clinical signs and physical examination findings besides neuroimaging and EEG, elevated levels of lactate should be taken into account when evaluating a patient with impaired consciousness. On the other hand, the suggested cut-off value 2.43mmol/l might not have a discriminative effect between GTCS, PNES, and syncope in female patients. This finding should be verified in a prospectively designed study with a larger patient population. Copyright © 2017 Elsevier Inc. All rights reserved.

Low serum vitamin B12 is associated with recurrent pregnancy loss in Syrian women.

PubMed

Hübner, Ulrich; Alwan, Ahmad; Jouma, Muhidin; Tabbaa, Mohammad; Schorr, Heike; Herrmann, Wolfgang

2008-01-01

Hyperhomocysteinemia and B-vitamin deficiency are associated with recurrent abortion. Recent studies have not investigated functional markers of vitamin B12 deficiency, such as methylmalonic acid. A total of 43 consecutive Syrian women with unexplained recurrent abortion and 32 pregnant controls were enrolled in the study. Serum folate, vitamin B12, methylmalonic acid and plasma homocysteine were determined. Vitamin B12 was significantly decreased in patients with recurrent abortion compared to controls (mean concentrations 197 vs. 300 pg/mL, p=0.004). The lowest mean serum vitamin B12 (172 pg/mL) was observed in primary aborters. Homocysteine was elevated in aborters in comparison to controls (8.3 vs. 7.1 micromol/L, p=0.093). Folate and methylmalonic acid did not differ significantly between the study groups. A highly significant correlation between homocysteine and methylmalonic acid and vitamin B12 was observed only in patients but not in controls (p<0.001 and p=0.002, respectively). In the logistic regression model, only serum vitamin B12 emerged with a significant odds ratio. The results confirm low serum vitamin B12 in recurrent abortion patients. However, methylmalonic acid did not support that functional vitamin B12 plays a role in this group. This unexpected result might be due to a decrease of the metabolically inert vitamin B12 fraction (holohaptocorrin) or confounding factors. Further studies are necessary to investigate the role of vitamin B12 deficiency in recurrent abortion.

Thyrotropin receptor autoantibodies and early miscarriages in patients with Hashimoto thyroiditis: a case-control study.

PubMed

Toulis, Konstantinos A; Goulis, Dimitrios G; Tsolakidou, Konstantina; Hilidis, Ilias; Fragkos, Marios; Polyzos, Stergios A; Gerofotis, Antonios; Kita, Marina; Bili, Helen; Vavilis, Dimitrios; Daniilidis, Michail; Tarlatzis, Basil C; Papadimas, Ioannis

2013-08-01

We have previously hypothesized that early miscarriage in women with Hashimoto thyroiditis might be the result of a cross-reactivity process, in which blocking autoantibodies against thyrotropin receptor (TSHr-Ab) antagonize hCG action on its receptor on the corpus luteum. To test this hypothesis from the clinical perspective, we investigated the presence of TSHr-Ab in Hashimoto thyroiditis patients with apparently unexplained, first-trimester recurrent miscarriages compared to that in Hashimoto thyroiditis patients with documented normal fertility. A total of 86 subjects (43 cases and 43 age-matched controls) were finally included in a case-control study. No difference in the prevalence of TSHr-Ab positivity was detected between cases and controls (Fisher's exact test, p value = 1.00). In patients with recurrent miscarriages, TSHr-Ab concentrations did not predict the number of miscarriages (univariate linear regression, p value = 0.08). These results were robust in sensitivity analyses, including only cases with full investigation or those with three or more miscarriages. We conclude that no role could be advocated for TSHr-Ab in the aetiology of recurrent miscarriages in women with Hashimoto thyroiditis.

The effect of low-dose ovarian stimulation with HMG plus progesterone on pregnancy outcome in women with history of recurrent pregnancy loss and secondary infertility: a retrospective cohort study.

PubMed

Coccia, Maria Elisabetta; Rizzello, Francesca; Cozzolino, Mauro; Turillazzi, Valentina; Capezzuoli, Tommaso

2018-06-01

We assessed the outcome of pregnancy in women with a history of recurrent pregnancy loss (RPL) following treatment with low-dose human menopausal gonadotropin (HMG)+progesterone or progesterone alone. This single-center retrospective cohort study included data from women diagnosed with RPL and treated between February 2005 and December 2012 with one cycle of HMG + progesterone or progesterone alone. Primary endpoint was the rate of ongoing pregnancies and losses by treatment, age (<38 vs. ≥38 years) and in the subgroup with unexplained RPL. Of 169 RPL patients, 35.5% (n = 60) received HMG + progesterone and 64.5% (n = 109) progesterone alone. Compared to progesterone alone, HMG + progesterone led to a lower, although not significant, frequency of losses (3.3% vs. 11.9%, p = .09) and a twofold higher rate of ongoing pregnancies (41.7% vs. 19.3%, p = .002). Similar results were obtained in the subgroup of patients with unexplained RPL (ongoing pregnancies: 48.1% upon HMG + progesterone vs. 21.3% upon progesterone, p = .03; losses: 0% vs. 8.5%, respectively, p = .29) and in those <38 years (ongoing pregnancies: 47.4% vs. 18.8%, respectively, p = .003; losses: 5.3% vs. 10.9% respectively, p = .47). These findings suggest that HMG in women with RPL may reduce the rate of miscarriages and increase that of live births regardless of RPL cause and in women aged <38 years.

HSV-1/HSV-2 Infection-Related Cancers in Bantu Populations Driving HIV-1 Prevalence in Africa: Tracking the Origin of AIDS at the Onset of the 20th Century.

PubMed

Le Goaster, Jacqueline; Bouree, Patrice; El Sissy, Franck N; Phuong Bui, Florence; Pokossy Epee, Johanna; Rollin, Paul; Tangy, Frédéric; Haenni, Anne-Lise

2016-01-01

At the onset of the 20th century, ancient clinical observations of cancer epidemics in Bantu populations of Sub-Saharan Africa were discovered. They were reported from 1914 to 1960, but remained unexplained. In 1983, in San Francisco, Calif., USA, cancer epidemics were related to infections by the human immunodeficiency virus type 1 (HIV-1) known as AIDS disease. Yet since 1996, it is known that HIV-1 strains are not the only ones involved. In Sub-Saharan Africa, recurrent orobuccal herpes simplex virus type 1 (HSV-1) and genital recurrent herpes simplex virus type 2 (HSV-2) appeared many times prior to infection by HIV-1. Data on these ancient medical observations regarding African cancer epidemics can today be referred to as the relationship between the unfortunate immune deficiency of herpes in Bantu populations and HIV-1 viral strains. For centuries, the Bantu populations dispersed in forests were living in close proximity to chimpanzees infected by simian immunodeficiency virus (SIV) and were exposed to SIV contamination which became HIV-1 in human beings. Presently, these unexplained Bantu cancer epidemics can be linked to the viral partnership of HSV-1/HSV-2 to HIV-1 strains. The key issue is now to prevent HSV-1/HSV-2 diseases related to HIV-1. An anti-herpes treatment administered early during childhood to Bantu populations will offer a mean of preventing herpes diseases related to HIV-1 infection and hence avoid cancer epidemics.

HSV-1/HSV-2 Infection-Related Cancers in Bantu Populations Driving HIV-1 Prevalence in Africa: Tracking the Origin of AIDS at the Onset of the 20th Century

PubMed Central

Le Goaster, Jacqueline; Bouree, Patrice; El Sissy, Franck N.; Phuong Bui, Florence; Pokossy Epee, Johanna; Rollin, Paul; Tangy, Frédéric; Haenni, Anne-Lise

2016-01-01

Introduction At the onset of the 20th century, ancient clinical observations of cancer epidemics in Bantu populations of Sub-Saharan Africa were discovered. They were reported from 1914 to 1960, but remained unexplained. In 1983, in San Francisco, Calif., USA, cancer epidemics were related to infections by the human immunodeficiency virus type 1 (HIV-1) known as AIDS disease. Yet since 1996, it is known that HIV-1 strains are not the only ones involved. In Sub-Saharan Africa, recurrent orobuccal herpes simplex virus type 1 (HSV-1) and genital recurrent herpes simplex virus type 2 (HSV-2) appeared many times prior to infection by HIV-1. Case Reports Data on these ancient medical observations regarding African cancer epidemics can today be referred to as the relationship between the unfortunate immune deficiency of herpes in Bantu populations and HIV-1 viral strains. For centuries, the Bantu populations dispersed in forests were living in close proximity to chimpanzees infected by simian immunodeficiency virus (SIV) and were exposed to SIV contamination which became HIV-1 in human beings. Presently, these unexplained Bantu cancer epidemics can be linked to the viral partnership of HSV-1/HSV-2 to HIV-1 strains. Conclusion The key issue is now to prevent HSV-1/HSV-2 diseases related to HIV-1. An anti-herpes treatment administered early during childhood to Bantu populations will offer a mean of preventing herpes diseases related to HIV-1 infection and hence avoid cancer epidemics. PMID:28413399

[Laboratory diagnostics in transient loss of consciousness : Serum lactate compared to serum creatine kinase as diagnostic indicator for generalized tonic-clonic seizures].

PubMed

Dafotakis, M; Heckelmann, J; Zechbauer, S; Litmathe, J; Brokmann, J; Willmes, K; Surges, R; Matz, O

2018-03-21

Laboratory parameters can help in the differential diagnostics of acute episodes of transient loss of consciousness. Especially serum lactate and serum creatine kinase (CK) levels may provide valuable hints to distinguish generalized tonic-clonic seizures (GTCS) from syncope. Serum lactate levels at admission and CK levels 10-48 h after the episodes that led to admission were compared between patients with GTCS (n = 30) and those with syncope (n = 15). In addition, sensitivity and specificity of lactate and CK as diagnostic markers for syncope and GTCS were determined. The serum lactate and serum CK levels were significantly increased in patients with GTCS as compared to syncope patients (serum lactate: p < 0.001; CK: p < 0.005). The area under the curve (AUC) for serum lactate as an indicator for GTCS was 0.94 (95% confidence interval [CI] 0.88-1.0). For CK the receiver operating characteristics (ROC) analysis produced an AUC of only 0.77 (95% CI: 0.63-0.9). The determination of the lactate value as point-of-care diagnostics appears to be highly relevant in the rapid clarification of unclear episodes with transient loss of consciousness. The CK level at follow-up is also suitable for distinguishing GTCS from syncope but is inferior to the serum lactate value.

Thrombophilia and Recurrent Pregnancy Loss

PubMed Central

Abu-Heija, Adel

2014-01-01

The association between thrombophilia and recurrent pregnancy loss (RPL) has become an undisputed fact. Thorombophilia creates a hypercoaguable state which leads to arterial and/or venous thrombosis at the site of implantation or in the placental blood vessels. Anticoagulants are an effective treatment against RPL in women with acquired thrombophilia due to antiphospholipid syndrome. The results of the use of anticoagulants for treating RPL in women with inherited thrombophilia (IT) are encouraging, but recently four major multicentre studies have shown that fetal outcomes (determined by live birth rates) may not be as favourable as previously suggested. Although the reported side-effects for anticoagulants are rare and usually reversible, the current recommendation is not to use anticoagulants in women with RPL and IT, or for those with unexplained losses. This review examines the strength of the association between thrombophilia and RPL and whether the use of anticoagulants can improve fetal outcomes. PMID:24516750

Pancreatic Cancer in Pregnancy Presenting with Thromboembolic Events: Case Report and Review of the Literature.

PubMed

Wakefield, Brian W; Masterson, Crystal M C; Borges, Manuel T; Hurt, K Joseph

2018-06-08

Stroke and hepatic vein thrombosis are highly associated with neoplasia but are extremely rare events in young, pregnant women. Rare and recurrent thrombotic events in pregnancy increase the suspicion for occult malignancy. We describe the case of a healthy 31-year-old G2P1 who presented with visual changes and dysarthria during pregnancy. Imaging showed cerebral infarcts. Her thrombophilia evaluation was negative. During delivery, she was diagnosed with fulminant Budd-Chiari Syndrome. Hepatic ultrasound suggested malignancy or metastasis, and postpartum CT scan and biopsy confirmed the diagnosis of Stage IV pancreatic cancer. Although rare in pregnancy, a new diagnosis of malignancy should be considered in patients with recurrent unexplained hypercoagulable complications. We propose an evidence-based algorithm for evaluation of occult malignancy in pregnancy based upon this case and review of the literature. © 2018 S. Karger AG, Basel.

[Dehydration and metabolic alkalosis: an unusual presentation of cystic fibrosis in an infant].

PubMed

Aranzamendi, Roberto J; Breitman, Fanny; Asciutto, Carolina; Delgado, Norma; Castaños, Claudio

2008-10-01

Cystic fibrosis (CF) may present during neonatal period with classic clinic symptoms related to the disease. The severity of the disease is multifactorial, one of the factors depends on the level of activity of the CFTR protein, which is related with the mutation type that affects the patient. An infant is presented who developed recurrent episodes of vomiting, anorexia, weight loss, dehydration and electrolyte abnormalities, such as metabolic alkalosis, hyponatremia, hypokalemia and hypochloremia. CF was diagnosed after the third episode showing an unusual and not very publicized presentation of the disease. Mutations !F 508 and 2789+5G-A were found. CF should be considered in patients of any age, but particularly in infants, presenting with anorexia, vomiting, failure to thrive, that are associated with recurrent episodes of hyponatremic hypochloremic, dehydration with metabolic alkalosis unexplained by other causes, even in the absence of respiratory or gastrointestinal symptoms or failure to thrive.

Lysosomal storage disorders: A review of the musculoskeletal features.

PubMed

James, Rebecca A; Singh-Grewal, Davinder; Lee, Senq-J; McGill, Jim; Adib, Navid

2016-03-01

The lysosomal storage disorders are a collection of progressive, multisystem disorders that frequently present in childhood. Their timely diagnosis is paramount as they are becoming increasingly treatable. Musculoskeletal manifestations often occur early in the disease course, hence are useful as diagnostics clues. Non-inflammatory joint stiffness or pain, carpal tunnel syndrome, trigger fingers, unexplained pain crises and short stature should all prompt consideration of a lysosomal storage disorder. Recurrent ENT infections, hepatosplenomegaly, recurrent hernias and visual/hearing impairment - especially when clustered together - are important extra-skeletal features. As diagnostic and therapeutic options continue to evolve, children with lysosomal storage disorders and their families are facing more sophisticated options for screening and treatment. The aim of this article is to highlight the paediatric presentations of lysosomal storage disorders, with an emphasis on the musculoskeletal features. © 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

77 FR 20873 - Qualification of Drivers; Application for Exemptions; Implantable Cardioverter Defibrillators

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-06

... infarction, angina pectoris, coronary insufficiency, thrombosis, or any other cardiovascular disease of a... clinical diagnosis of a cardiovascular disease (1) which is accompanied by symptoms of syncope, dyspnea... cardiovascular disease which is accompanied by and/or likely to cause symptoms of syncope, dyspnea, collapse, or...

Syncope: what is the trigger?

PubMed

Hainsworth, R

2003-02-01

Although a syncopal attack is frequently preceded by prodromal symptoms, sometimes the onset can be so abrupt that there is no warning at all. The switch in autonomic responses responsible for such an attack is quite rapid and dramatic, but the trigger for this remains one of the unresolved mysteries in cardiovascular physiology.

Safe single-dose administration of propofol in patients with established Brugada syndrome: a retrospective database analysis.

PubMed

Flamée, Panagiotis; De Asmundis, Carlo; Bhutia, Jigme T; Conte, Giulio; Beckers, Stefan; Umbrain, Vincent; Verborgh, Christian; Chierchia, Gian-Battista; Van Malderen, Sophie; Casado-Arroyo, Rubén; Sarkozy, Andrea; Brugada, Pedro; Poelaert, Jan

2013-12-01

Propofol is an anesthetic drug with a very attractive pharmacokinetic profile, which makes it the induction agent of choice, especially in day-case surgery. Data on its potential proarrhythmic effects in patients with Brugada syndrome (BS) patients are still lacking. The aim of our study was to investigate whether a single dose of propofol triggered any adverse events in consecutive high-risk patients with BS. All consecutive patients with BS having undergone an implantable cardiac defibrillator implantation under general anesthesia were eligible for this study. The anesthetic chart of each patient was reviewed, and the occurrence of malignant arrhythmic events as well as the need for defibrillation during induction and maintenance of anesthesia was investigated. Further monitoring of the patient comprised five-lead electrocardiogram (ECG), pulse oxymetry, and continuous carbon dioxide monitoring through side sampling from the ventilator tubes. Anesthesia was induced with propofol and sufentanyl. Injection of propofol occurred in a single-shot bolus-as often performed by most anesthetists-over a few seconds. Anesthesia was maintained with volatile anesthetics (sevoflurane or desflurane) in an oxygen-air mixture. From 1996 to 2011, 57 high-risk patients with BS (35 males; mean age: 43 ± 16 years) underwent an automated implantable cardioverter defibrillator implantation at our center using propofol as induction drug of general anesthesia. Three patients had a history of spontaneous type I ECG, three had aborted sudden death, and 51 had a history of recurrent or unexplained syncope. The induction dose ranged between 0.8 mg/kg and 5.0 mg/kg (2.2 ± 0.7 mg/kg). Only one case received propofol to maintain anesthesia. The surgical procedure involved an anesthetic period of 75 ± 25 minutes. No patient developed a malignant rhythm during induction and maintenance of anesthesia. All patients were then safely discharged from the postanesthetic care unit after 1 hour. No adverse events were noticed during the recovery phase. In our study, administration of a single-dose propofol in patients with BS was safe. Nevertheless, extreme caution is still recommended when conducting general anesthesia in patients with BS, especially if BS patients are sedated with propofol for longer periods. ©2013, The Authors. Journal compilation ©2013 Wiley Periodicals, Inc.

Female third party lymphocytes are effective for immunotherapy of patients with unexplained primary recurrent spontaneous abortion: A retrospective analysis of outcomes.

PubMed

Liang, Xu; Qiu, Tian; Qiu, Lihua; Wang, Xipeng; Zhao, Aimin; Lin, Qide

2015-01-01

Allogeneic lymphocytes of paternal origin or supplied by a male third party have been used for the treatment of recurrent spontaneous abortion. Few studies, however, have examined the use of female third party lymphocytes. Our purpose was to determine whether female third party lymphocytes could be used for immunotherapy of women with recurrent spontaneous abortion. In this retrospective non-randomised cohort-controlled study, the medical records of patients with three or more spontaneous abortions who received immunotherapy with lymphocytes from their partner, a male third party or a female third party, as well as those who received no immunotherapy, from 1996 to 2012 were reviewed. All patients were negative for mixed lymphocyte culture reaction (MLR)-blocking antibodies. Immunotherapy was performed in 302 patients in two courses, while 53 patients received no immunotherapy. The pregnancy rates in patients who received lymphocytes from their partners, a male third party or a female third party, and in those not immunised, were 85.6%, 87.3%, 89.7%, and 79.3%, respectively (p = 0.523);the live birth rates were 87.3%, 75.8%, 84.6%, and 40.5%, respectively (p < 0.001). We conclude that female third party lymphocytes can be used for immunotherapy in patients with recurrent spontaneous abortion.

Syncopal episode as the presenting symptom of jugular vein thrombosis in pregnancy: a case report.

PubMed

Merhi, Zaher O; Haberman, Shoshana

2007-06-01

Jugular vein thrombosis has been reported to occur in pregnant women who conceived with assisted reproductive technology (ART). A 28-year-old woman at 17 weeks' gestation presented to the emergency room with a syncopal episode. She reported no arm pain or swelling, no neck pain or swelling, and no dyspnea or difficulty swallowing. Doppler sonography of the neck vasculature revealed acute bilateral internal jugular vein thromboses. Thrombophilia workup was normal. Intravenous anticoagulation with heparin was initiated, and the patient was discharged on low-molecular-weight heparin. Though rare, jugular vein thrombosis should be considered in the differential diagnosis of syncopal episodes even in women who conceive without ART.

[Neurohumoral mechanisms for vasovagal syncopes. Part I].

PubMed

Gajek, Jacek; Zyśko, Dorota

2003-04-01

Vasovagal syncope is defined as a reflex loss of consciousness related to reaction to various stimuli as orthostatic stress, pain or emotions connected with loss of muscle postural tone. The aetiology of this disorder is still unknown. The imbalance between the parts of autonomic nervous system and other homeostasis-related systems as renin-angiotensin-aldosterone system, peptides as endothelin, neuropeptide Y, vasopressin, adrenomedullin and cAMP, adenosine and AMP can play an important role in the development of vasovagal syncope. In the first part of the paper the authors describe the mechanisms involved in the development of vasovagal reaction, pathophysiology of the head-up tilt test and the role of autonomic nervous system.

Carotid Space Mass Proximal to Vagus Nerve Causing Asystole and Syncope.

PubMed

Leviter, Julie; Wiznia, Daniel H

2016-01-01

Manipulation of vagal nerve rootlets, whether surgical or through mass effect of a neoplasm, can result in asystole and hypotension, accompanied by ST depression and right bundle branch block. There are few case reports of a neoplasm causing these effects, and this case describes a patient with such a mass presenting with syncopal episodes. A 43-year-old man with a past medical history of HIV, bipolar disorder, and epilepsy was admitted to the neurology service for a video electroencephalogram (vEEG) to characterize syncopal episodes that were felt to be epileptic in origin. During the study, he experienced symptoms of his typical aura, which correlated with a transient symptomatic high degree AV block on telemetry, and an absence of epileptic findings on vEEG. Magnetic Resonance Imaging (MRI) of the brain showed a mass in the left posterior carotid space at the skull base. The patient underwent permanent dual chamber MRI-compatible pacemaker placement for his heart block. His syncopal episodes resolved, but presyncopal symptoms persisted. We discuss the presentation and treatment of vagal neoplasms.

Neurogenic orthostatic hypotension - management update and role of droxidopa.

PubMed

Vijayan, Joy; Sharma, Vijay K

2015-01-01

Orthostatic hypotension (OH) is defined as a significant decrease in blood pressure (BP) during the first 3 minutes of standing or a head up on a tilt table. Symptoms of OH are highly variable, ranging from mild light-headedness to recurrent syncope. OH occurs due to dysfunction of one or more components of various complex mechanisms that interplay closely to maintain BP in a normal range during various physiological and associated disease states. Various biochemical and electrophysiological studies are often undertaken to assess the severity and etiology of OH. In addition to the lifestyle modifications, various medications that stimulate the adrenergic receptors or increase central blood volume are used in patients with OH. Droxidopa is a newer agent that increases the levels of norepinephrine in postganglionic sympathetic neurons. Management strategies for OH are presented, including the mechanism of action of droxidopa and various studies performed to assess its efficacy.

OK-432 injection therapy for cystadenocarcinoma of the parotid gland: A case report.

PubMed

Makiyama, Kiyoshi; Hirai, Ryoji; Iikuni, Fusako; Ikeda, Atsuo; Tomomatsu, Hirotaka

2016-01-01

OK-432 is an immunomodulator that has been reported to be efficacious as an injection therapy for cervical lymphomas and ranulas. We performed OK-432 injection therapy to treat a cystadenocarcinoma of the parotid gland in a 72-year-old man. The 50 × 46-mm tumor was located in the deep lobe of the gland. The tumor had compressed the glossopharyngeal, vagus, and hypoglossal nerves, causing neurally mediated syncope, hoarseness, dysphagia, and dysarthria. A concentration of 5 KE/2 ml of OK-432 was injected. Within 2 months, the cyst had disappeared; no recurrence was apparent during 59 months of follow-up. To the best of our knowledge, no previous report has described injection of OK-432 for malignant cystic disease. We describe the injection method, injection dose, and postinjection course in the hope that this information will prove useful for future applications against malignant cystic disease.

Neurogenic orthostatic hypotension – management update and role of droxidopa

PubMed Central

Vijayan, Joy; Sharma, Vijay K

2015-01-01

Orthostatic hypotension (OH) is defined as a significant decrease in blood pressure (BP) during the first 3 minutes of standing or a head up on a tilt table. Symptoms of OH are highly variable, ranging from mild light-headedness to recurrent syncope. OH occurs due to dysfunction of one or more components of various complex mechanisms that interplay closely to maintain BP in a normal range during various physiological and associated disease states. Various biochemical and electrophysiological studies are often undertaken to assess the severity and etiology of OH. In addition to the lifestyle modifications, various medications that stimulate the adrenergic receptors or increase central blood volume are used in patients with OH. Droxidopa is a newer agent that increases the levels of norepinephrine in postganglionic sympathetic neurons. Management strategies for OH are presented, including the mechanism of action of droxidopa and various studies performed to assess its efficacy. PMID:26089676

A typical presentations of hypothyroidism and associated problems in Ibadan, Nigeria.

PubMed

Balogun, F M; Jarrett, O O

2015-06-01

Hypothyroidism can present atypically making its recognition difficult especially in resource limited settings. CASE PRESENTATION AND MANAGEMENT: Two children presented with atypical features of hypothyroidism with resultant delay in diagnosis. Patient I presented with persistent respiratory distress, facial swelling and recurrent syncopal attacks. Cardiovascular examination was normal except for pulmonary hypertension. He did not respond to conventional supportive therapy and hypothyroidism was discovered much later. Patient II was a seven month old male infant with abdominal swelling, bilateral pitting leg oedema, poor weight gain and delayed developmental milestones. Examination revealed ascites and pericardial effusion. He was being managed for protein energy malnutrition until he was found to have hypothyroidism and was successfully managed with L thyroxin. A typical presentations of hypothyroidism in resource limited settings can result in delay in diagnosis and treatment which can lead to unnecessary morbidity and mortality. High index of suspicion and expertise are therefore required.

Brainstem dysfunction protects against syncope in multiple sclerosis.

PubMed

Habek, Mario; Krbot Skorić, Magdalena; Crnošija, Luka; Adamec, Ivan

2015-10-15

The aim of this study was to investigate the correlation between autonomic dysfunction in multiple sclerosis (MS) and brainstem dysfunction evaluated with the vestibular evoked myogenic potentials (VEMP) score and conventional MRI. Forty-five patients with the diagnosis of clinically isolated syndrome (CIS) suggestive of MS were enrolled. VEMP, heart rate, and blood pressure responses to the Valsalva maneuver, heart rate response to deep breathing, and pain provoked head-up tilt table test, as well as brain and spinal cord MRI were performed. There was no difference in the VEMP score between patients with and without signs of sympathetic or parasympathetic dysfunction. However, patients with syncope had significantly lower VEMP score compared to patients without syncope (p<0.01). Patients with orthostatic hypotension (OH) showed a trend of higher VEMP score compared to patients without OH (p=0.06). There was no difference in the presence of lesions in the brainstem or cervical spinal cord between patients with or without any of the studied autonomic parameters. The model consisting of a VEMP score of ≤5 and normal MRI of the midbrain and cervical spinal cord has sensitivity and specificity of 83% for the possibility that the patient with MS can develop syncope. Pathophysiological mechanisms underlying functional and structural disorders of autonomic nervous system in MS differ significantly. While preserved brainstem function is needed for development of syncope, structural disorders like OH could be associated with brainstem dysfunction. Copyright © 2015 Elsevier B.V. All rights reserved.

Certain cardiovascular indices predict syncope in the postural tachycardia syndrome

NASA Technical Reports Server (NTRS)

Sandroni, P.; Opfer-Gehrking, T. L.; Benarroch, E. E.; Shen, W. K.; Low, P. A.

1996-01-01

Patients with postural tachycardia syndrome (POTS) represent a patient population with orthostatic intolerance; some are prone to syncope, others are not. The underlying neurocardiovascular mechanisms are not completely understood. The current study was undertaken to assess if certain cardiovascular indices are predictive of syncope in POTS. We compared the response to tilt-up and the Valsalva maneuver in four groups: POTS patients who fainted (POTS-f; n = 11;31 +/- 11 years): POTS patients who did not faint (POTS-nf; n = 9; 29 +/- 9 years); normal controls (NLS; n = 13; 39 +/- 11 years); patients with generalized autonomic failure with orthostatic hypotension and syncope (n = 10; 59 +/- 14 years). Beat-to-beat heart rate (HR), systolic arterial pressure, diastolic arterial pressure (DAP) and pulse pressure (PP) were monitored using Finapres. Cardiac output, stroke volume (SV) and end-diastolic volume (EDV), and calculated total peripheral resistance (TPR) were recorded using thoracic electrical bioimpedance. An autonomic reflex screen which quantitates the distribution and severity of autonomic failure was also done. With the patient supine, all POTS patients (POTS-nf; POTS-f) had increased HR (p < 0.001) and reduced SV/EDV (p < 0.001) when compared with NLS. On tilt-up, POTS-f patients were significantly different from both NLS and POTS-nf patients; the most consistent alteration was a fall instead of an increase in TPR; other changes were a greater reduction in PP, a reduction (instead of an increment) in DAP, and a different pattern of changes during the Valsalva maneuver (excessive early phase II, attenuated or absent late phase II). Our results suggest alpha-adrenergic impairment with increased pooling or hypovolemia in POTS-f patients. We conclude that it is possible to identify the mechanism of syncope in POTS patients, and perhaps other patients with orthostatic intolerance and an excessive liability to syncope.

Knowledge translation of the American College of Emergency Physicians' clinical policy on syncope using computerized clinical decision support.

PubMed

Melnick, Edward R; Genes, Nicholas G; Chawla, Neal K; Akerman, Meredith; Baumlin, Kevin M; Jagoda, Andy

2010-06-01

To influence physician practice behavior after implementation of a computerized clinical decision support system (CDSS) based upon the recommendations from the 2007 ACEP Clinical Policy on Syncope. This was a pre-post intervention with a prospective cohort and retrospective controls. We conducted a medical chart review of consecutive adult patients with syncope. A computerized CDSS prompting physicians to explain their decision-making regarding imaging and admission in syncope patients based upon ACEP Clinical Policy recommendations was embedded into the emergency department information system (EDIS). The medical records of 410 consecutive adult patients presenting with syncope were reviewed prior to implementation, and 301 records were reviewed after implementation. Primary outcomes were physician practice behavior demonstrated by admission rate and rate of head computed tomography (CT) imaging before and after implementation. There was a significant difference in admission rate pre- and post-intervention (68.1% vs. 60.5% respectively, p = 0.036). There was no significant difference in the head CT imaging rate pre- and post-intervention (39.8% vs. 43.2%, p = 0.358). There were seven physicians who saw ten or more patients during the pre- and post-intervention. Subset analysis of these seven physicians' practice behavior revealed a slight significant difference in the admission rate pre- and post-intervention (74.3% vs. 63.9%, p = 0.0495) and no significant difference in the head CT scan rate pre- and post-intervention (42.9% vs. 45.4%, p = 0.660). The introduction of an evidence-based CDSS based upon ACEP Clinical Policy recommendations on syncope correlated with a change in physician practice behavior in an urban academic emergency department. This change suggests emergency medicine clinical practice guideline recommendations can be incorporated into the physician workflow of an EDIS to enhance the quality of practice.

Bed Rest and Orthostatic-Hypotensive Intolerance

NASA Technical Reports Server (NTRS)

Schneider, Suzanne M.

2000-01-01

Orthostatic tolerance may be defined as the ability of humans to maintain cerebral perfusion and consciousness upon movement from a supine or sitting position to the upright posture; for example, subjects can stand suddenly or be tilted to the head-up body position. Similar but not identical physiological responses can be induced by positive G(sub Z) (head to foot) acceleration or exposure to lower body negative pressure (LBNP). The objective is to suddenly shift blood to the lower body to determine how effectively cardiovascular and neural-hormonal compensatory responses react to maintain blood pressure. In the most precise method for measuring tolerance, individuals would be stressed until they faint (syncope). However, the potential consequences and discomforts of such a test usually prohibit such a procedure so that few investigators actually induce syncope. In a more common approach, subjects are exposed to a given level of stress, for example, head-up tilt for 15 min, and any increases in heart rate or decreases in blood pressure are interpreted as indicators of progress toward syncope. Presumably, the greater the perturbation of heart rate and blood pressure, the closer to "tolerance," i.e., point of unconsciousness. Another more appropriate approach is to induce a progressively increasing hypotensive stress until pre-determined physiological responses or pre-syncopal symptoms appear. The physiological criteria may include a sudden drop in systolic blood pressure (greater than 25 mm/min), a sudden drop in heart rate (greater than 15 beats/min), or a systolic blood pressure less than 70 mmHg. The most common pre-syncopal symptoms include lightheadedness, stomach awareness or distress, feelings of warmth, tingly skin, and light to profuse sweating. Usually a combination of physiological responses and symptoms occurs such that, on different days, the tolerance time to the same orthostatic protocol is reproducible for a given individual. The assumption is that by taking subjects to near fainting, one can determine their tolerance. This latter pre-syncopal approach is better for estimating orthostatic or hypotensive tolerance than the former measurement of heart rate and blood pressure responses to a given stress. There is considerable variability in individual responses to orthostasis. For example, some subjects are "heart-rate responders" and have a pronounced cardiovascular response similar to that when performing moderately hard aerobic exercise, whereas others may experience pre-syncopal symptoms with very little increase in heart rate. Some individuals have a slow, gradual fall in blood pressure to orthostasis, and others have little change in blood pressure until a sudden precipitous fall in pressure occurs just prior to fainting. With both tilt and LBNP tests there is a low correlation between heart-rate or blood-pressure responses to a sub-tolerance stress as a measure of pre-syncopal limited orthostatic-hypotensive tolerance.

Diagnosis of Epilepsy and Related Episodic Disorders.

PubMed

St Louis, Erik K; Cascino, Gregory D

2016-02-01

This review identifies the diverse and variable clinical presentations associated with epilepsy that may create challenges in diagnosis and treatment. Epilepsy has recently been redefined as a disease characterized by one or more seizures with a relatively high recurrence risk (ie, 60% or greater likelihood). The implication of this definition for therapy is that antiepileptic drug therapy may be initiated following a first seizure in certain situations.EEG remains the most commonly used study in the evaluation of people with epilepsy. Routine EEG may assist in diagnosis, classification of seizure type(s), identification of treatment, and monitoring the efficacy of therapy. Video-EEG monitoring permits seizure classification, assessment of psychogenic nonepileptic seizures, and evaluation of candidacy for epilepsy surgery. MRI is pivotal in elucidating the etiology of the seizure disorder and in suggesting the localization of seizure onset. This article reviews the new International League Against Epilepsy practical clinical definition for epilepsy and the differential diagnosis of other physiologic paroxysmal spells, including syncope, parasomnias, transient ischemic attacks, and migraine, as well as psychogenic nonepileptic seizures. The initial investigational approaches to new-onset epilepsy are considered, including neuroimaging and neurophysiologic investigations with interictal and ictal video-EEG. Neurologists should maintain a high index of suspicion for epilepsy when children or adults present with a single paroxysmal spell or recurrent episodic events.

Long term effects of cilostazol in a dog with sick sinus syndrome.

PubMed

Kanno, Nobuyuki; Suzuki, Tomohiro

2017-06-16

Sick sinus syndrome (SSS) is a type of bradyarrhythmia that can lead to syncope. Cilostazol has been reported to be an effective treatment for human patients with SSS and other bradyarrhythmias. This report describes the successful long-term treatment with cilostazol in a dog with SSS. A nine-year old intact male Miniature Schnauzer presented with a history of syncopal episodes and unsteady gait. After cilostazol treatment, the total heart rate (HR), mean HR, and frequency of premature ventricular contractions (PVCs) increased, while the maximum HR and maximum pause time decreased. Additionally, the number of syncopal episodes decreased. The dog died suddenly, 1,418 days after the start of cilostazol treatment. Cilostazol may be a useful therapeutic agent in canines with SSS.

[Patients with inherited trombophilia and recurrent pregnancy loss: incidence].

PubMed

Flores-Alatriste, José Daniel; Jacobo-Nájera, Sara; Segura-Rodríguez, Rubén; Stern-Colin y Nunes, Jorge Jaroslav

2014-06-01

Inherited thrombophilia is a genetic tendency to suffer thrombotic events clinically evident at an early age, with frequent re- currences without apparent cause. In recent years thrombophilia has earned a place as a primary risk factor for abnormal pregnancy. To determine the incidence of hereditary thrombophilia in patients with recurrent pregnancy loss. A retrospective, linear and descriptive study was conducted at Clinic of Reproduction IMMUNOREP with patients treated from January 2007 to December 2012. The study included patients with a diagnosis of recurrent pregnancy loss and inherited thrombophilia with laboratory studies of thrombophilia including different genes: G1619A (factor V Leiden), R2 H1299R (factor V polymorphism), C677T (methylenetetrahydrofolate reductase enzyme polymorphism), A1298C (methylenetetrahydrofolate reductase enzyme mutation), G20210A (mutation of the prothrombin gene), V34L (factor XIII polymorphism), 455G > A (fibrinogen gene mutation), 4G/5G (plasminogen activator inhibitor) and a/b L33P (ribosomal polymorphism of methylenetetrahydrofolate reductase enzyme). 211 files were reviewed and only 10.4% of patients were negative for hereditary thrombophilia, a percentage that is consistent with the results of different series of studies in patients with unexplained recurrent pregnancy loss. The most prevalent genetic condition was 4G/5G (plasminogen activator inhibitor, 85.5%) in homozygous and heterozygous with 63.4% (120) and 22.4% (42), respectively. It was demonstrated the direct relationship between thrombophilia and recurrent pregnancy loss depending on whether the patient is heterozygous or homozygous for the disease.

Recurrent miscarriage.

PubMed

Duckitt, Kirsten; Qureshi, Aysha

2008-04-14

Recurrent miscarriage is the spontaneous loss of three or more consecutive pregnancies with the same biological father in the first trimester, and affects 1-2% of women, half of whom have no identifiable cause. Overall, 75% of affected women will have a successful subsequent pregnancy, but this rate falls for older mothers and with increasing number of miscarriages. Antiphospholipid syndrome, with anticardiolipin or lupus anticoagulant antibodies, is present in 15% of women with recurrent first and second trimester miscarriage. We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for unexplained recurrent miscarriage? What are the effects of treatments for recurrent miscarriage caused by antiphospholipid syndrome? We searched: Medline, Embase, The Cochrane Library and other important databases up to April 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We found 14 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. In this systematic review we present information relating to the effectiveness and safety of the following interventions: aspirin (low dose), bed rest, corticosteroids, early scanning in subsequent pregnancies, heparin plus low-dose aspirin, human chorionic gonadotrophin, intravenous immunoglobulin treatment, lifestyle adaptation, oestrogen, paternal white cell immunisation, progesterone, trophoblastic membrane infusion, and vitamin supplementation.

Recurrent miscarriage.

PubMed

Duckitt, Kirsten; Qureshi, Aysha

2011-02-01

Recurrent miscarriage is the spontaneous loss of three or more consecutive pregnancies with the same biological father in the first trimester, and affects 1% to 2% of women, half of whom have no identifiable cause. Overall, 75% of affected women will have a successful subsequent pregnancy, but this rate falls for older mothers and with increasing number of miscarriages. Antiphospholipid syndrome, with anticardiolipin or lupus anticoagulant antibodies, is present in 15% of women with recurrent first and second trimester miscarriage. We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for unexplained recurrent miscarriage? What are the effects of treatments for recurrent miscarriage caused by antiphospholipid syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We found 14 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. In this systematic review we present information relating to the effectiveness and safety of the following interventions: aspirin (low dose), bed-rest, corticosteroids, early scanning in subsequent pregnancies, heparin plus low-dose aspirin, human chorionic gonadotrophin, intravenous immunoglobulin treatment, lifestyle adaptation, oestrogen, paternal white cell immunisation, progesterone, trophoblastic membrane infusion, and vitamin supplementation.

[Recurrent pulmonary infection and oral mucosal ulcer].

PubMed

Kuang, Fei-Mei; Tang, Lan-Lan; Zhang, Hui; Xie, Min; Yang, Ming-Hua; Yang, Liang-Chun; Yu, Yan; Cao, Li-Zhi

2017-04-01

An 8-year-old girl who had experienced intermittent cough and fever over a 3 year period, was admitted after experiencing a recurrence for one month. One year ago the patient experienced a recurrent oral mucosal ulcer. Physical examination showed vitiligo in the skin of the upper right back. Routine blood tests and immune function tests performed in other hospitals had shown normal results. Multiple lung CT scans showed pulmonary infection. The patient had recurrent fever and cough and persistent presence of some lesions after anti-infective therapy. The antitubercular therapy was ineffective. Routine blood tests after admission showed agranulocytosis. Gene detection was performed and she was diagnosed with dyskeratosis congenita caused by homozygous mutation in RTEL1. Patients with dyskeratosis congenita with RTEL1 gene mutation tend to develop pulmonary complications. Since RTEL1 gene sequence is highly variable with many mutation sites and patterns and can be inherited via autosomal dominant or recessive inheritance, this disease often has various clinical manifestations, which may lead to missed diagnosis or misdiagnosis. For children with unexplained recurrent pulmonary infection, examinations of the oral cavity, skin, and nails and toes should be taken and routine blood tests should be performed to exclude dyskeratosis congenita. There are no specific therapies for dyskeratosis congenita at present, and when bone marrow failure and pulmonary failure occur, hematopoietic stem cell transplantation and lung transplantation are the only therapies. Androgen and its derivatives are effective in some patients. Drugs targeting the telomere may be promising for patients with dyskeratosis congenita.

Clinical and electrophysiological evaluation of pediatric Wolff-Parkinson-White patients

PubMed Central

Yıldırım, Işıl; Özer, Sema; Karagöz, Tevfik; Şahin, Murat; Özkutlu, Süheyla; Alehan, Dursun; Çeliker, Alpay

2015-01-01

Objective: Wolff-Parkinson-White (WPW) syndrome presents with paroxysmal supraventricular tachycardia and is characterized by electrocardiographic (ECG) findings of a short PR interval and a delta wave. The objective of this study was to evaluate the electrophysiological properties of children with WPW syndrome and to develop an algorithm for the management of these patients with limited access to electrophysiological study. Methods: A retrospective review of all pediatric patients who underwent electrophysiological evaluation for WPW syndrome was performed. Results: One hundred nine patients underwent electrophysiological evaluation at a single tertiary center between 1997 and 2011. The median age of the patients was 11 years (0.1-18). Of the 109 patients, 82 presented with tachycardia (median age 11 (0.1-18) years), and 14 presented with syncope (median age 12 (6-16) years); 13 were asymptomatic (median age 10 (2-13) years). Induced AF degenerated to ventricular fibrillation (VF) in 2 patients. Of the 2 patients with VF, 1 was asymptomatic and the other had syncope; the accessory pathway effective refractory period was ≤180 ms in both. An intracardiac electrophysiological study was performed in 92 patients, and ablation was not attempted for risk of atrioventricular block in 8 (8.6%). The success and recurrence rate of ablation were 90.5% and 23.8% respectively. Conclusion: The induction of VF in 2 of 109 patients in our study suggests that the prognosis of WPW in children is not as benign as once thought. All patients with a WPW pattern on the ECG should be assessed electrophysiologically and risk-stratified. Ablation of patients with risk factors can prevent sudden death in this population. PMID:26006136

Impact of borderline-subclinical hypothyroidism on subsequent pregnancy outcome in women with unexplained recurrent pregnancy loss.

PubMed

Uchida, Sayaka; Maruyama, Tetsuo; Kagami, Maki; Miki, Fumie; Hihara, Hanako; Katakura, Satomi; Yoshimasa, Yushi; Masuda, Hirotaka; Uchida, Hiroshi; Tanaka, Mamoru

2017-06-01

Because subclinical hypothyroidism (thyroid-stimulating hormone [TSH] > 4.5 IU/mL) is associated with adverse pregnancy outcome, including early pregnancy loss, TSH is recommended to be titrated to ≤2.5 mIU/L in levothyroxine-treated women before pregnancy. The purpose of this study was to determine whether borderline-subclinical hypothyroidism (borderline-SCH; 2.5 < TSH ≤ 4.5 IU/mL) affects the outcome of subsequent pregnancies in women with unexplained recurrent pregnancy loss (uRPL). After workup for antinuclear antibody (ANA), anti-phospholipid syndrome, thrombophilia, uterine abnormalities, hormone disorders, and/or chromosomal abnormalities, 317 women with a history of uRPL were enrolled. The women were classified into two groups: borderline-SCH, and euthyroidism (0.3 ≤ TSH ≤ 2.5 IU/mL). All women had normal serum free thyroxine (T4) and did not receive levothyroxine before or during the subsequent pregnancy. There were no significant differences in age, number of previous pregnancy losses, number of live births, or body mass index between the borderline-SCH (n = 56) and the euthyroid (n = 261) groups, but the rate of ANA positivity differed significantly (53.6% vs 33.7%, respectively; P = 0.005). The subsequent pregnancy rate did not differ between the two groups (55.4%, 31/56 vs 51.3%, 134/261, respectively). The pregnancy loss rate (<22 weeks of gestation) tended to be higher in the borderline-SCH than the euthyroid group (29.0%, 9/31 vs 17.9%, 24/134), although not significantly so (P = 0.16). Although some subset of uRPL is though to be due to as-yet-unidentified cause(s), borderline-SCH is unlikely to be involved in uRPL. © 2017 Japan Society of Obstetrics and Gynecology.

Consequences of Clostridium difficile infection: understanding the healthcare burden.

PubMed

Bouza, E

2012-12-01

Clostridium difficile is the leading cause of infectious nosocomial diarrhoea in developed countries, with a measured incidence of approximately five episodes per 10,000 days of hospital stay in Europe. Accurate diagnosis of C. difficile infection (CDI) is a prerequisite for obtaining reliable epidemiological data, but in many European countries diagnosis is probably suboptimal. A significant percentage of CDI cases are missed because clinicians often fail to request tests for C. difficile toxins in cases of unexplained diarrhoea. In addition, some laboratories continue to use tests of low sensitivity or apply them inappropriately. In one study in Spain, failure to request CDI testing in more than two-thirds of patients with unexplained diarrhoea led to significant underdiagnosis of cases. A recent pan-European survey revealed huge discrepancies in the rate of CDI testing across Europe, which suggests that epidemiological reports underestimate the true incidence of CDI in many parts of Europe. This is important because, as this review of the clinical and economic burden of CDI illustrates, infection with C. difficile imposes a significant burden not only on patients, owing to increased morbidity and mortality, but also on healthcare systems and society in general. On the basis of current incidence rates, annual costs for management of CDI amount to approximately $800 million in the USA and €3000 million in Europe. Moreover, estimates suggest that costs associated with recurrent CDI can exceed those of primary CDI. Measures to more effectively prevent CDI and reduce CDI recurrence rates may help to reduce this burden. © 2012 The Author Clinical Microbiology and Infection © 2012 European Society of Clinical Microbiology and Infectious Diseases.

Comparison of different risk stratification systems in predicting short-term serious outcome of syncope patients.

PubMed

Safari, Saeed; Baratloo, Alireza; Hashemi, Behrooz; Rahmati, Farhad; Forouzanfar, Mohammad Mehdi; Motamedi, Maryam; Mirmohseni, Ladan

2016-01-01

Determining etiologic causes and prognosis can significantly improve management of syncope patients. The present study aimed to compare the values of San Francisco, Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL), Boston, and Risk Stratification of Syncope in the Emergency Department (ROSE) score clinical decision rules in predicting the short-term serious outcome of syncope patients. The present diagnostic accuracy study with 1-week follow-up was designed to evaluate the predictive values of the four mentioned clinical decision rules. Screening performance characteristics of each model in predicting mortality, myocardial infarction (MI), and cerebrovascular accidents (CVAs) were calculated and compared. To evaluate the value of each aforementioned model in predicting the outcome, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were calculated and receiver-operating curve (ROC) curve analysis was done. A total of 187 patients (mean age: 64.2 ± 17.2 years) were enrolled in the study. Mortality, MI, and CVA were seen in 19 (10.2%), 12 (6.4%), and 36 (19.2%) patients, respectively. Area under the ROC curve for OESIL, San Francisco, Boston, and ROSE models in prediction the risk of 1-week mortality, MI, and CVA was in the 30-70% range, with no significant difference among models ( P > 0.05). The pooled model did not show higher accuracy in prediction of mortality, MI, and CVA compared to others ( P > 0.05). This study revealed the weakness of all four evaluated models in predicting short-term serious outcome of syncope patients referred to the emergency department without any significant advantage for one among others.

Long term effects of cilostazol in a dog with sick sinus syndrome

PubMed Central

KANNO, Nobuyuki; SUZUKI, Tomohiro

2017-01-01

Sick sinus syndrome (SSS) is a type of bradyarrhythmia that can lead to syncope. Cilostazol has been reported to be an effective treatment for human patients with SSS and other bradyarrhythmias. This report describes the successful long-term treatment with cilostazol in a dog with SSS. A nine-year old intact male Miniature Schnauzer presented with a history of syncopal episodes and unsteady gait. After cilostazol treatment, the total heart rate (HR), mean HR, and frequency of premature ventricular contractions (PVCs) increased, while the maximum HR and maximum pause time decreased. Additionally, the number of syncopal episodes decreased. The dog died suddenly, 1,418 days after the start of cilostazol treatment. Cilostazol may be a useful therapeutic agent in canines with SSS. PMID:28458273

Non-visualized pregnancy losses are prognostically important for unexplained recurrent miscarriage.

PubMed

Kolte, A M; van Oppenraaij, R H; Quenby, S; Farquharson, R G; Stephenson, M; Goddijn, M; Christiansen, O B

2014-05-01

Are non-visualized pregnancy losses (biochemical pregnancy loss and failed pregnancy of unknown location combined) in the reproductive history of women with unexplained recurrent miscarriage (RM) negatively associated with the chance of live birth in a subsequent pregnancy? Non-visualized pregnancy losses contribute negatively to the chance for live birth: each non-visualized pregnancy loss confers a relative risk (RR) for live birth of 0.90 (95% CI 0.83; 0.97), equivalent to the RR conferred by each additional clinical miscarriage. The number of clinical miscarriages prior to referral is an important determinant for live birth in women with RM, whereas the significance of non-visualized pregnancy losses is unknown. A retrospective cohort study comprising 587 women with RM seen in a tertiary RM unit 2000-2010. Data on the outcome of the first pregnancy after referral were analysed for 499 women. The study was conducted in the RM Unit at Rigshospitalet, Copenhagen, Denmark. We included all women with unexplained RM, defined as ≥3 consecutive clinical miscarriages or non-visualized pregnancy losses following spontaneous conception or homologous insemination. The category 'non-visualized pregnancy losses' combines biochemical pregnancy loss (positive hCG, no ultrasound performed) and failed PUL (pregnancy of unknown location, positive hCG, but on ultrasound, no pregnancy location established). Demographics were collected, including BMI, age at first pregnancy after referral and outcome of pregnancies prior to referral. Using our own records and records from other Danish hospitals, we verified the outcome of the first pregnancy after referral. For each non-visualized pregnancy loss and miscarriage in the women's reproductive history, the RR for live birth in the first pregnancy after referral was determined by robust Poisson regression analysis, adjusting for risk factors for negative pregnancy outcome. Non-visualized pregnancy losses constituted 37% of reported pregnancies prior to referral among women with RM. Each additional non-visualized pregnancy loss conferred an RR for live birth of 0.90 (95% CI 0.83; 0.97), which was not statistically significantly different from the corresponding RR of 0.87 (95% CI 0.80; 0.94) conferred by each clinical miscarriage. Among women with ≥2 clinical miscarriages, a reduced RR for live birth was also shown: 0.82 (95% CI 0.74; 0.92) for each clinical miscarriage and 0.89 (95% CI 0.80; 0.98) for each non-visualized pregnancy loss, respectively. Surgically treated ectopic pregnancies (EPs) were significantly more common for women with primary RM and no confirmed clinical miscarriages, compared with women with primary RM and ≥1 clinical miscarriage (22 versus 6%, difference 16% (95% CI 9.1%; 28.7%); RR for ectopic pregnancy was 4.0 (95% CI 1.92; 8.20). RM was defined as ≥3 consecutive pregnancy losses before 12 weeks' gestation, and we included only women with unexplained RM after thorough evaluation. It is uncertain whether the findings apply to other definitions of RM and among women with known causes for their miscarriages. To our knowledge, this is the first comprehensive investigation of prior non-visualized pregnancy losses and their prognostic significance for live birth in a subsequent pregnancy in women with unexplained RM. We show that a prior non-visualized pregnancy loss has a negative prognostic impact on subsequent live birth and is thus clinically significant. None. N/A.

A 43-year-old woman with unexplained elevation of hCG.

PubMed

Johnson, Lisa M; Gniadek, Thomas J; Cohn, Claudia S; Bachowski, Gary; Karger, Amy B

2018-05-01

This case report investigates an unusual hCG result in a woman who is not pregnant. A 43-year-old woman was admitted for recurrence of thrombotic thrombocytopenic purpura (TTP) and therapeutic plasma exchange (TPE) was initiated. Prior to transitioning the patient from TPE to immunosuppressive therapy, a serum qualitative hCG test was performed and was positive. Several etiologies for elevated hCG were considered and investigated, including heterophile antibody interference, endogenous hCG from pituitary or malignancy, and exogenous hCG. Retrospective measurement of hCG levels in remnant samples, including a sample obtained prior to TPE initiation, demonstrated that the hCG elevation occurred with plasma administration for TPE. Further investigation with the American Red Cross confirmed that a plasma donor was unknowingly pregnant and in the latter half of the first trimester at the time of donation, when hCG levels peak. In plasma recipients with unexplained hCG elevation, passive transfer of hCG from plasma should be considered in the differential diagnosis. Retrospective measurement of hCG in remnant samples obtained prior to plasma exchange can assist in confirming the source. Copyright © 2018 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Diagnosis of Adult Patients with Cystic Fibrosis.

PubMed

Nick, Jerry A; Nichols, David P

2016-03-01

The diagnosis of cystic fibrosis (CF) is being made with increasing frequency in adults. Patients with CF diagnosed in adulthood typically present with respiratory complaints, and often have recurrent or chronic airway infection. At the time of initial presentation individuals may appear to have clinical manifestation limited to a single organ, but with subclinical involvement of the respiratory tract. Adult-diagnosed patients have a good response to CF center care, and newly available cystic fibrosis transmembrane receptor-modulating therapies are promising for the treatment of residual function mutation, thus increasing the importance of the diagnosis in adults with unexplained bronchiectasis. Copyright © 2016 Elsevier Inc. All rights reserved.

Anti-ma2 paraneoplastic encephalitis in association with recurrent cervical cancer.

PubMed

Ney, Douglas E; Messersmith, Wells; Behbakht, Kian

2014-07-01

Paraneoplastic neurological syndromes are rare, and although they are frequently associated with gynecological malignancies, cervical cancer is a rare cause. The symptoms of anti-Ma2 encephalitis are diverse and often present prior to the diagnosis of malignancy. We report a case of a 37-year-old woman with a history of cervical cancer presenting with unexplained weight gain and vertical supranuclear gaze palsy. Magnetic resonance imaging of the brain revealed lesions within the bilateral hypothalami and midbrain. Anti-Ma2 antibodies were eventually found in the serum, prompting a search for malignancy. Recurrent metastatic cervical cancer was found in the retroperitoneal lymph nodes. This is the first report of cervical cancer in association with anti-Ma2 encephalitis, and highlights the need for a high degree of suspicion in patients with a cancer history presenting with neurological symptoms. The symptoms associated with anti-Ma2 encephalitis are diverse and typically precede the diagnosis of cancer in patients, and should trigger a search for an underlying malignancy.

Decreased endometrial vascularity and receptivity in unexplained recurrent miscarriage patients during midluteal and early pregnancy phases.

PubMed

Tan, Shu-Yin; Hang, Fu; Purvarshi, Gowreesunkur; Li, Min-Qing; Meng, Da-Hua; Huang, Ling-Ling

2015-10-01

To evaluate the predictive value of three-dimensional (3D)-power Doppler sonography on recurrent miscarriage. The study patients were divided into a recurrent miscarriage group (30 cases) and a normal pregnancy group (21 cases). Measurement of endometrial thickness was performed using two-dimensional transvaginal ultrasound in the midluteal phase. The endometrial volume, vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) in midluteal and placenta volume, as well as the VI, FI, and VFI of early pregnancy were measured using Virtual Organ Computer-aided Analysis of 3D-power Doppler ultrasound. Endometrial thickness, endometrial volume, endometrial vascular data, VI, FI, and VFI of the midluteal phase were lower in the recurrent miscarriage group compared with the normal pregnancy group (p < 0.05). Placental volume, VI, and VFI during early pregnancy were lower in the miscarriage group compared with the normal pregnancy group (p < 0.05). There was no significant change in FI between the recurrent miscarriage and control groups during early pregnancy (p > 0.05). The predictive accuracy of endometrial thickness, endometrial volume, VI, FI, and VFI in the midluteal phase, and placenta volume, VI, FI, and VFI in early pregnancy as measured by the receiver operating characteristic curve to predict miscarriage before 12 gestational weeks in participants was 0.681, 0.876, 0.770, 0.720, 0.879, 0.771, 0.907, 0.592, respectively. The 3D-power Doppler ultrasound is a more comprehensive and sensitive method for evaluating endometrial receptivity. Endometrial volume, VI, FI, and VFI in the midluteal phase, as well as VI in early pregnancy, can be considered as predictive factors for recurrent miscarriage. Copyright © 2015. Published by Elsevier B.V.

Drinking Water to Prevent Postvaccination Presyncope in Adolescents: A Randomized Trial.

PubMed

Kemper, Alex R; Barnett, Elizabeth D; Walter, Emmanuel B; Hornik, Christoph; Pierre-Joseph, Natalie; Broder, Karen R; Silverstein, Michael; Harrington, Theresa

2017-11-01

Postvaccination syncope can cause injury. Drinking water prephlebotomy increases peripheral vascular tone, decreasing risk of blood-donation presyncope and syncope. This study evaluated whether drinking water prevaccination reduces postvaccination presyncope, a potential syncope precursor. We conducted a randomized trial of subjects aged 11 to 21 years receiving ≥1 intramuscular vaccine in primary care clinics. Intervention subjects were encouraged to drink 500 mL of water, with vaccination recommended 10 to 60 minutes later. Control subjects received usual care. Presyncope symptoms were assessed with a 12-item survey during the 20-minutes postvaccination. Symptoms were classified with a primary cutoff sensitive for presyncope, and a secondary, more restrictive cutoff requiring greater symptoms. Results were adjusted for clustering by recruitment center. There were 906 subjects randomly assigned to the control group and 901 subjects randomly assigned to the intervention group. None had syncope. Presyncope occurred in 36.2% of subjects by using the primary definition, and in 8.0% of subjects by using the restrictive definition. There were no significant differences in presyncope by intervention group for the primary (1-sided test, P = .24) or restrictive outcome (1-sided test, P = .17). Among intervention subjects vaccinated within 10 to 60 minutes after drinking all 500 mL of water ( n = 519), no reduction in presyncope was observed for the primary or restrictive outcome (1-sided tests, P = .13, P = .17). In multivariable regression analysis, presyncope was associated with younger age, history of passing out or nearly passing out after a shot or blood draw, prevaccination anxiety, receiving >1 injected vaccine, and greater postvaccination pain. Drinking water before vaccination did not prevent postvaccination presyncope. Predictors of postvaccination presyncope suggest opportunities for presyncope and syncope prevention interventions. Copyright © 2017 by the American Academy of Pediatrics.

Comparison of different risk stratification systems in predicting short-term serious outcome of syncope patients

PubMed Central

Safari, Saeed; Baratloo, Alireza; Hashemi, Behrooz; Rahmati, Farhad; Forouzanfar, Mohammad Mehdi; Motamedi, Maryam; Mirmohseni, Ladan

2016-01-01

Background: Determining etiologic causes and prognosis can significantly improve management of syncope patients. The present study aimed to compare the values of San Francisco, Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL), Boston, and Risk Stratification of Syncope in the Emergency Department (ROSE) score clinical decision rules in predicting the short-term serious outcome of syncope patients. Materials and Methods: The present diagnostic accuracy study with 1-week follow-up was designed to evaluate the predictive values of the four mentioned clinical decision rules. Screening performance characteristics of each model in predicting mortality, myocardial infarction (MI), and cerebrovascular accidents (CVAs) were calculated and compared. To evaluate the value of each aforementioned model in predicting the outcome, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were calculated and receiver-operating curve (ROC) curve analysis was done. Results: A total of 187 patients (mean age: 64.2 ± 17.2 years) were enrolled in the study. Mortality, MI, and CVA were seen in 19 (10.2%), 12 (6.4%), and 36 (19.2%) patients, respectively. Area under the ROC curve for OESIL, San Francisco, Boston, and ROSE models in prediction the risk of 1-week mortality, MI, and CVA was in the 30–70% range, with no significant difference among models (P > 0.05). The pooled model did not show higher accuracy in prediction of mortality, MI, and CVA compared to others (P > 0.05). Conclusion: This study revealed the weakness of all four evaluated models in predicting short-term serious outcome of syncope patients referred to the emergency department without any significant advantage for one among others. PMID:27904602

Trazodone and Omeprazole Interaction causing Frequent Second-Degree Mobitz Type 1 Atrioventricular (AV) Block (Wenckebach Phenomenon) and Syncope: A Case Report and Literature Review

PubMed Central

Akinseye, Oluwaseun A.; Alfishawy, Mostafa; Radparvar, Farshid; Bakshi, Sanjiv

2015-01-01

Patient: Male, 54 Final Diagnosis: Trazodone and omeprazole interaction causing second-degree Mobitz type 1 AV block and syncope Symptoms: Syncope Medication: — Clinical Procedure: Trazodone and omeprazole withheld Specialty: Cardiology Objective: Unexpected drug reaction Background: This case report highlights serious cardiovascular adverse effects with a conventional dose of trazodone as a result of its potential interaction with omeprazole. Case Report: A 54-year-old man who was a former smoker, with dyslipidemia, coronary artery disease, and anxiety disorder developed lightheadedness and syncope the morning of admission. He was taking trazodone 50 mg daily, omeprazole 20 mg daily, and simvastatin 20 mg at bedtime. He doubled the dose of trazodone 50 mg on the night prior to presentation to calm his anxiety. An electrocardiogram revealed sinus rhythm at 60 beats per minute and second-degree Mobitz type 1 atrioventricular (AV) block with 5:4 AV conduction. Results of basic metabolic panel, thyroid-stimulating hormone, and chest radiograph were normal. A transthoracic echocardiogram revealed aortic valve sclerosis. We tested for Lyme disease given his history of hunting in the woods 8 months prior to presentation, but the titer was negative. Trazodone and omeprazole were discontinued. By the 3rd day of medication discontinuation, all symptoms had resolved and the frequency of second-degree AV Mobitz type 1 AV block had decreased to once per hour. Conclusions: Due diligence and meticulous attention to detail needs to be exercised to uncover drug interactions as potential causes of lethal and nonlethal patient symptomatology, as in this case of syncope caused by concomitant use of trazodone and a widely prescribed medication, omeprazole. PMID:26017199

Postural Tachycardia Syndrome and Vasovagal Syncope: A Hidden Case of Obstructive Cardiomyopathy without Severe Septal Hypertrophy

PubMed Central

Ho, Natalie; Shields, Robert W.; Cremer, Paul; Rodriguez, L. Leonardo

2018-01-01

A 36-year-old female with symptoms of orthostatic intolerance and syncope was diagnosed with vasovagal syncope on a tilt table test and with postural tachycardia syndrome (POTS) after a repeat tilt table test. However, an echocardiogram at our institution revealed obstructive cardiomyopathy without severe septal hypertrophy, with a striking increase in left ventricular outflow tract gradient from 7 mmHg at rest to 75 mmHg during Valsalva, with a septal thickness of only 1.3 cm. Cardiac MRI showed an apically displaced multiheaded posteromedial papillary muscle with suggestion of aberrant chordal attachments to the anterior mitral leaflet contributing to systolic anterior motion of the mitral valve. She underwent surgery with reorientation of the posterior medial papillary muscle head, resection of the tethering secondary chordae to the A1 segment of the mitral valve, chordal shortening and tacking of the chordae to the A1 and A2 segments of the mitral valve, and gentle septal myectomy. After surgery, she had significant improvement in her prior symptoms. To our knowledge, this is the first reported case of obstructive cardiomyopathy without severe septal hypertrophy with abnormalities in papillary muscle and chordal attachment, in a patient diagnosed with vasovagal syncope and POTS. PMID:29850268

Postural Tachycardia Syndrome and Vasovagal Syncope: A Hidden Case of Obstructive Cardiomyopathy without Severe Septal Hypertrophy.

PubMed

Mayuga, Kenneth A; Ho, Natalie; Shields, Robert W; Cremer, Paul; Rodriguez, L Leonardo

2018-01-01

A 36-year-old female with symptoms of orthostatic intolerance and syncope was diagnosed with vasovagal syncope on a tilt table test and with postural tachycardia syndrome (POTS) after a repeat tilt table test. However, an echocardiogram at our institution revealed obstructive cardiomyopathy without severe septal hypertrophy, with a striking increase in left ventricular outflow tract gradient from 7 mmHg at rest to 75 mmHg during Valsalva, with a septal thickness of only 1.3 cm. Cardiac MRI showed an apically displaced multiheaded posteromedial papillary muscle with suggestion of aberrant chordal attachments to the anterior mitral leaflet contributing to systolic anterior motion of the mitral valve. She underwent surgery with reorientation of the posterior medial papillary muscle head, resection of the tethering secondary chordae to the A1 segment of the mitral valve, chordal shortening and tacking of the chordae to the A1 and A2 segments of the mitral valve, and gentle septal myectomy. After surgery, she had significant improvement in her prior symptoms. To our knowledge, this is the first reported case of obstructive cardiomyopathy without severe septal hypertrophy with abnormalities in papillary muscle and chordal attachment, in a patient diagnosed with vasovagal syncope and POTS.

Design and use of a quantitative scale for measuring presyncope.

PubMed

Sheldon, Robert S; Amuah, Joseph E; Connolly, Stuart J; Rose, Sarah; Morillo, Carlos A; Talajic, Mario; Kus, Teresa; Fouad-Tarazi, Fetnat; Klingenheben, Thomas; Krahn, Andrew D; Sheldon, Aaron; Koshman, Mary-Lou; Ritchie, Debbie

2009-08-01

Vasovagal syncope is common and distressing. One important symptom is presyncope, but there are no clinimetric measures of this. We developed the Calgary Presyncope Form (CPF) and used it to test whether metoprolol reduces presyncope in a randomized trial. The CPF captures the frequency, duration, and severity of presyncope. We administered it to participants in the Prevention of Syncope Trial (POST), a randomized clinical trial that tested the hypothesis that metoprolol reduces syncope and presyncope in adult patients with vasovagal syncope. The CPF was completed by 44 patients on metoprolol and 39 patients on placebo, of a total of 208 subjects. Completion of the CPF for each of the threedimensions was 84-87% in the 83 respondents. Results were centrally distributed in duration and severity dimensions, but not in frequency. Patients had a median of 1.2 presyncopal spells per day, with a median moderate severity, lasting a median 10 minutes. The 3 scales were statistically independent of each other. These results were independent of subject age, and results in all 3 dimensions were stable over the observation period. There was no significant difference between patients on metoprolol and placebo in any dimension. The 3-dimensional CPF is simple, easy to use, stable over time, measures 3 independent variables, and documents that metoprolol does not reduce presyncope.

Head up tilt test in the diagnosis of neurocardiogenic syncope in childhood and adolescence.

PubMed

Udani, Vrajesh; Bavdekar, Manisha; Karia, Samir

2004-06-01

Neurocardiogenic syncope (NCS) is a common paroxysmal disorder that is often misdiagnosed as a seizure disorder. Head up tilt test (HUTT) has been used to confirm this diagnosis. There is no data available of its use in children / adolescents from India. To study the usefulness of the HUTT in children and adolescents with suspected NCS. This was a part retrospective and later prospective study set in a tertiary child neurology outpatient department (OPD). Patients with a strong clinical suspicion of syncope were recruited for the study. Clinical and treatment details were either retrieved from the chart or prospectively recorded in later patients. The HUTT was then carried out at baseline and after provocation and the results correlated with the clinical diagnosis. Eighteen children with a mean age of 10.8 years were studied. Eight had precipitating factors. Thirteen had premonitory symptoms. Pallor, temperature change, diaphoresis, headache, tonic / clonic movements, post-ictal confusion and peri-ictal headache were symptoms noticed. Sixteen had a positive HUTT. Seven were on long-term anti-epileptic drugs (AEDs). Two had epileptiform abnormalities on their electroencephalogram (EEG). The diagnosis of syncope is often confused with epilepsy. Head up tilt test has a high sensitivity in the diagnosis of NCS in children / adolescents. It is fairly safe and easy to perform.

Lead intoxication due to ayurvedic medications as a cause of abdominal pain in adults.

PubMed

Mehta, Varun; Midha, Vandana; Mahajan, Ramit; Narang, Vikram; Wander, Praneet; Sood, Ridhi; Sood, Ajit

2017-02-01

Though a majority of cases of lead intoxication come from occupational exposures, traditional and folk remedies have also been reported to contain toxic amounts of lead. We present a large series of patients with lead poisoning due to intake of Ayurvedic medicines, all of whom presented with unexplained abdominal pain. This was a retrospective, observational case series from a tertiary care center in India. The charts of patients who underwent blood lead level (BLL) testing as a part of workup for unexplained abdominal pain between 2005 and 2013 were reviewed. The patients with lead intoxication (BLLs >25 μg/dl) were identified and demographics, history, possible risk factors, clinical presentation and investigations were reviewed. Treatment details, duration, time to symptomatic recovery, laboratory follow-up and adverse events during therapy were recorded. BLLs were tested in 786 patients with unexplained abdominal pain and high levels were identified in 75 (9.5%) patients, of which a majority (73 patients, 9.3%) had history of Ayurvedic medication intake and only two had occupational exposure. Five randomly chosen Ayurvedic medications were analyzed and lead levels were impermissibly high (14-34,950 ppm) in all of them. Besides pain in abdomen, other presenting complaints were constipation, hypertension, neurological symptoms and acute kidney injury. Anemia and abnormal liver biochemical tests were observed in all the 73 patients. Discontinuing the Ayurvedic medicines and chelation with d-penicillamine led to improvement in symptoms and reduction in BLLs in all patients within 3-4 months. The patients presenting with severe recurrent abdominal pain, anemia and history of use of Ayurvedic medicines should be evaluated for lead toxicity. Early diagnosis in such cases can prevent unnecessary investigations and interventions, and permits early commencement of the treatment.

[Indices of 24-hour monitoring of arterial blood pressure in patients with neurogenic syncope and patients with chronic constitution- dependent hypotension].

PubMed

Musaeva, Z A; Khapaev, B A; Fedotova, A V; Oknin, V Iu

1999-01-01

Clinical-psychologic study, spectral analysis of heart rate variability, 24-h monitoring of arterial pressure (AP) were performed in 20 patients with chronic constitutional arterial hypotension and in 18 patients with neurogenic syncopal states. Both groups were characterised by considerable manifestations of the syndrome of autonomic dystonia, by emotional-personal disorders that correlated with elevated level of slow-waves of the second order in heart rhythms' spectrum. That testified activation of supersegmental sympathetic-adrenal systems. Disorders in sympathetic-parasympathetic correlations were specific in each group. In patients with arterial hypotension disorder of circadian rhythm was observed in the form of superfluous decrease of diastolic AP during sleep. Circadian rhythms in patients with neurogenic syncopes have parameters characteristic for normals showing a preverved chronobiologic AP regulation. A role of the alterations revealed in pathogenesis of arterial hypotensionis discussed.

Munchausen Syndrome by Proxy: two case reports and an update of the literature.

PubMed

Moldavsky, Maria; Stein, Daniel

2003-01-01

Munchausen Syndrome by Proxy (MSP) may significantly hamper the normal development of children. Our aim was to describe the first two Israeli children who fit this diagnosis. Case #1 was diagnosed at the age of seven months with failure to thrive, severe recurrent vomiting, and recurrent unexplained fever. Medical tests performed were normal. No improvement was noted following prolonged treatment, which included several surgical interventions. Case #2 was hospitalized at the age of four years because of recurrent convulsive episodes. Medical examinations performed were normal, and there was no improvement in the reported seizure disorder despite continuous treatment. In both cases, MSP was suspected because of a persistent illness that could not be explained by adequate medical basis, and because the symptoms and signs occurred only in the mother's presence. A confrontation was made, leading to rapid deterioration of the hitherto devoted relationship of the mother of case #1 with her child, and of the previous cooperative relationship of both mothers with the medical staff. Removal of both children from their families ensued, with considerable improvement within a brief period, which continued in a one- to two-year follow-up period. The study reviews the required diagnostic criteria for MSP and possible treatment options.

Primary osseous tumours of the elbow: 60 years of registry experience

PubMed Central

Halai, Mansur; Gupta, Sanjay; Wallace, David; Rymaszewski, Lech; Mahendra, Ashish

2015-01-01

Background We present the largest series of surgically treated primary bone tumours of the elbow in the English literature (75 cases). We sought to identify characteristics specific to these lesions and recommend an investigatory protocol. Methods The national registry and case notes were reviewed between 1954-2014. Tumours were classified according to Enneking's spectrum. Results There were no benign latent cases in this series as these were managed locally. All patients presented with persistent rest pain, with or without swelling. The distal humerus, in contrast to the proximal radius and ulna, was responsible for the majority and the more aggressive cases. Misdiagnosis was evident in 13% of cases; most of which were attributed to simple bone cysts. All patients that were referred required surgical intervention to either establish the diagnosis or for treatment. Benign tumours had a 19% recurrence rate, with giant cell tumour the most aggressive. Malignant tumours carried 39% local recurrence rate and a 5-year mortality of 61%. Conclusions The suspicion of a tumour should be raised in the patient with unremitting, unexplained, non-mechanical bony elbow pain. These echo the NICE recommendations and we recommend prompt specialist referral. With high rates of local recurrence, we recommend close postoperative monitoring. PMID:27582988

Comparable vitamin D3 metabolism in the endometrium of patients with recurrent spontaneous abortion and fertile controls.

PubMed

Tavakoli, Maryam; Salek-Moghaddam, Alireza; Jeddi-Tehrani, Mahmood; Talebi, Saeed; Kazemi-Sefat, Golnaz-Ensieh; Vafaei, Sedigheh; Mohammadzadeh, Afsaneh; Sheikhhassani, Shahrzad; Zarnani, Amir-Hassan

2015-05-01

Vitamin D exerts important roles during pregnancy, and its deficiency may be associated with several pregnancy complications, including pregnancy loss, yet no data are available for molecules involved in vitamin D metabolism in patients with unexplained recurrent spontaneous abortion. In this study, we investigated possible difference in endometrial expression of vitamin D3 receptor (VDR), 1α-hydroxylase (CYP27B1), and 24-hydroxylase (CYP24A1) in women with recurrent spontaneous abortion (n = 8) and healthy controls (n = 8). Gene expression of VDR, CYP27B1, and CYP24A1 was determined by real-time PCR, while VDR and CYP27B1 proteins were localized by immunohistochemistry and their abundance was validated by Western blot. We found that both patient and control groups expressed comparable levels of endometrial VDR, CYP27B1, and CYP24A1 transcripts. In line with the gene-expression results, CYP27B1 and different isoforms of VDR protein were present at the same abundance in the endometria of both groups. No significant alteration in VDR and CYP27B1 immunoreactivity pattern was found in the endometrium of patients compared to fertile controls, however. The results of the present study, therefore, do not support the hypothesis of differential expression of key molecules involved in vitamin D3 metabolism in the endometrium of recurrent spontaneous abortion patients and fertile controls. © 2015 Wiley Periodicals, Inc.

Electrocardiogram findings in emergency department patients with syncope.

PubMed

Quinn, James; McDermott, Daniel

2011-07-01

To determine the sensitivity and specificity of the San Francisco Syncope Rule (SFSR) electrocardiogram (ECG) criteria for determining cardiac outcomes and to define the specific ECG findings that are the most important in patients with syncope. A consecutive cohort of emergency department (ED) patients with syncope or near syncope was considered. The treating emergency physicians assessed 50 predictor variables, including an ECG and rhythm assessment. For the ECG assessment, the physicians were asked to categorize the ECG as normal or abnormal based on any changes that were old or new. They also did a separate rhythm assessment and could use any of the ECGs or available monitoring strips, including prehospital strips, when making this assessment. All patients were followed up to determine a broad composite study outcome. The final ECG criterion for the SFSR was any nonsinus rhythm or new ECG changes. In this specific study, the initial assessments in the database were used to determine only cardiac-related outcomes (arrhythmia, myocardial infarction, structural, sudden death) based on set criteria, and the authors determined the sensitivity and specificity of the ECG criteria for cardiac outcomes only. All ECGs classified as "abnormal" by the study criteria were compared to the official cardiology reading to determine specific findings on the ECG. Univariate and multivariate analysis were used to determine important specific ECG and rhythm findings. A total of 684 consecutive patients were considered, with 218 having positive ECG criteria and 42 (6%) having important cardiac outcomes. ECG criteria predicted 36 of 42 patients with cardiac outcomes, with a sensitivity of 86% (95% confidence interval [CI] = 71% to 94%), a specificity of 70% (95% CI = 66% to 74%), and a negative predictive value of 99% (95% CI = 97% to 99%). Regarding specific ECG findings, any nonsinus rhythm from any source and any left bundle conduction problem (i.e., any left bundle branch block, left anterior fascicular block, left posterior fascicular block, or QRS widening) were 2.5 and 3.5 times more likely associated with significant cardiac outcomes. The ECG criteria from the SFSR are relatively simple, and if used correctly can help predict which patients are at risk of cardiac outcomes. Furthermore, any left bundle branch block conduction problems or any nonsinus rhythms found during the ED stay should be especially concerning for physicians caring for patients presenting with syncope. © 2011 by the Society for Academic Emergency Medicine.

Optimal Detection of a Localized Perturbation in Random Networks of Integrate-and-Fire Neurons.

PubMed

Bernardi, Davide; Lindner, Benjamin

2017-06-30

Experimental and theoretical studies suggest that cortical networks are chaotic and coding relies on averages over large populations. However, there is evidence that rats can respond to the short stimulation of a single cortical cell, a theoretically unexplained fact. We study effects of single-cell stimulation on a large recurrent network of integrate-and-fire neurons and propose a simple way to detect the perturbation. Detection rates obtained from simulations and analytical estimates are similar to experimental response rates if the readout is slightly biased towards specific neurons. Near-optimal detection is attained for a broad range of intermediate values of the mean coupling between neurons.

Hypopituitarism possibly due to lymphocytic hypophysitis in a patient with type 1 diabetes.

PubMed

Matoba, Keiichiro; Mitsuishi, Sumie; Hayashida, Satoshi; Yamazaki, Hiroyuki

2014-01-01

Hypopituitarism often develops insidiously, and undiagnosed hypopituitarism can influence the glycemic profile of patients with type 1 diabetes. We herein report the case of a 49-year-old man with type 1 diabetes and Hashimoto's thyroiditis who experienced an unexplained improvement in his glycemic level and recurrent severe hypoglycemia, despite a reduction in the dose of insulin. Based on the patient's endocrinological findings, he was diagnosed with hypopituitarism possibly due to lymphocytic hypophysitis, as supported by positive results for human leukocyte antigen A24 and Cw3. Following the administration of hydrocortisone replacement therapy, his insulin requirement increased to a premorbid level, and the severe hypoglycemia resolved.

Optimal Detection of a Localized Perturbation in Random Networks of Integrate-and-Fire Neurons

NASA Astrophysics Data System (ADS)

Bernardi, Davide; Lindner, Benjamin

2017-06-01

Experimental and theoretical studies suggest that cortical networks are chaotic and coding relies on averages over large populations. However, there is evidence that rats can respond to the short stimulation of a single cortical cell, a theoretically unexplained fact. We study effects of single-cell stimulation on a large recurrent network of integrate-and-fire neurons and propose a simple way to detect the perturbation. Detection rates obtained from simulations and analytical estimates are similar to experimental response rates if the readout is slightly biased towards specific neurons. Near-optimal detection is attained for a broad range of intermediate values of the mean coupling between neurons.

[Initial subretinal localization of acute myeloblastic leukemia (AML5) recurrence].

PubMed

Le Gall, S; François, S; Urier, N; Genevieve, F; d'Hermies, F; Rachieru, P; Ifrah, N

2001-10-13

Reduced visual acuity in patients with acute leucemia can result from many causes including an ocular localization. A patient previously treated for acute myeloblastic leucemia-5 (AML5) developed bilateral vision impairment related to a subretinal localization of the leucemia. Meningeal and bone marrow relapse followed. The subretinal localization responded only to massive systemic steroid treatment. Although asymptomatic, ocular localizations are frequent in leucemia. Their prognostic impact depends on the ocular structure involved and on the chronology of onset--early or late in the leucemia course. The underlying pathophysiological mechanism of ocular involvement remains unexplained but hyperleucocytosis at presentation may be a risk factor and would justify at least systematic specialized examinations and discussion of prophylactic treatment.

Atrial electromechanical conduction delay in patients with neurocardiogenic syncope.

PubMed

Sucu, Murat; Ercan, Suleyman; Uku, Okkes; Davutoglu, Vedat; Altunbas, Gokhan

2014-05-01

We aimed to investigate the presence of atrial electromechanical conduction delay in patients with neurocardiogenic syncope, which was diagnosed with head-up tilt table test (HUTT). A total of 29 patients (mean age: 30.6 ± 15.9 years) with vasovagal syncope, as diagnosed by HUTT, and 23 healthy control subjects (mean age: 34.7 ± 16.3 years) with a negative HUTT were enrolled to the study. Atrial electromechanical conduction delay was defined as the time elapsed from the beginning of the P wave in the electrogardiogram to the beginning of the Am wave in tissue Doppler. There was no statistically significant difference between the groups in terms of interatrial conduction delay, whereas the difference was significant with regard to the right intraatrial electromechanical conduction delay (P < 0.01) and the left intraatrial electromechanical conduction delay (P < 0.0001). There was a negative correlation between the left intraatrial electromechanical conduction delay and the right intraatrial electromechanical conduction delay (r = -0.486, P = 0.001), whereas a positive correlation was present with the interatrial electromechanical conduction delay (r = 0.507, P = 0.001). In this study, the tissue Doppler method revealed that there is left and right intraatrial electromechanical conduction delay in patients with vasovagal syncope. The impact and role of atrial conduction delay as a pathophysiological determinant should be confirmed in further studies. ©2013 Wiley Periodicals, Inc.

Cardiac myxoma: diagnostic approach, surgical treatment and follow-up. A twenty years experience.

PubMed

Jelic, J; Milicić, D; Alfirević, I; Anić, D; Baudoin, Z; Bulat, C; Corić, V; Dadić, D; Husar, J; Ivanćan, V; Korda, Z; Letica, D; Predrijevac, M; Ugljen, R; Vućemilo, I

1996-12-01

At the University Department of Cardiovascular Surgery in Zagreb, Croatia, we treated 81 patients with primary intracardiac myxoma, in a period from January 1975 to December 1994. There were 55 female and 26 male pts, in age from 1 month to 80 years, mean 46+/-15 years. Clinical manifestations varied from no symptoms and very poor or no clinical signs to various manifestations of chronic or acute congestive heart failure, syncope and arrhythmias with or without systemic findings such as high erythrocyte sedimentation rate, anaemia, leucocytosis, elevated gamma globulin, thrombocytopenia or low grade fever, as well as cerebrovascular accidents due to tumour embolization. Cardiac symptoms were predominant in 54 pts (66.6%) and cerebrovascular in 20 pts (24.7%). Seven pts (8.6%) were symptomless and discovered accidentally, mostly regarding on an unexplained heart murmur. In almost all the patients preoperative diagnosis of intracardiac myxoma was sufficiently established by echocardiography. The tumour was located in the left atrium in 62 pts (76.5%) and in the right atrium in 19 pts (23.5%). Delay from the onset of symptoms to the diagnosis was 6 months in average (range 10 days to 25 months). The average waiting for the operation was 9 days (range from 1 to 60 days). The echocardiographic diagnosis was confirmed during intraoperative examination followed by histological analysis. All pts underwent excision of myxoma using cardiopulmonary bypass with core and topical hypothermia and cold crystaloid cardioplegia. According to the additional preoperative and intraoperative findings, in 6 pts sinchronous mitral valve reconstruction, in 3 pts artificial mitral valve implantation and in 2 pts atrial wall reconstruction was performed. There was no perioperative mortality. After the operation, we could not evaluate all the patients long enough, mostly because of some paramedical circumstancies, such as war, migrations, etc. Twenty two pts undevent evaluation for at least 5 years after the operation. Among them there was no evidence of the tumour recurrence, 15 pts were asymptomatic and 7 had NYHA II class symptoms. For 17 pts with a left atrial myxoma preoperative and postoperative echocardiographic data were available for comparison, showing a significant reduction of the left atrial diameter (p<0.001) during the postoperative follow-up. Our data, presenting one of the biggest reports concerning cardiac myxomas, showed a broad spectrum of their clinical presentation, importance of echocardiography in diagnosing and postoperative follow-up and efficacy of a proper surgical intervention as a definite, curative therapy since there were no deaths and no significant cardiac dysfunction neither tumour reccurrence as well.

[Usefulness of a protocol for carotid sinus massage in supine and erect postures in patients with syncope without other cardiovascular or neurological diseases].

PubMed

Bocchiardo, M; Alciati, M; Buscemi, A; Cravetto, A; Richiardi, E; Gaita, F

1995-05-01

Carotid sinus massage is a first level test when investigating the cause of syncope. It is normally performed in the supine and erect positions. However, there is no standard complete protocol. So we have devised a new protocol to evaluate the utility of carotid sinus massage in different postures and the influence of patients age on the response. Two groups of subjects were selected: a group of 167 patients (mean age 50 ys +/- 18, 105 males, 62 females) with a history of syncope without cardiovascular and neurological disease and 20 asymptomatic control subjects (mean age 52 ys +/- 13, 11 males, 9 females). Carotid sinus massage was performed supine, just after passive tilt, after 5 minutes of tilt and just after passive return to supine. If a pause > 3" was detected, the protocol was repeated after atropine i.v. injection. Borderline vasodepressor: blood pressure reduction > 30 but < 50 mm Hg without symptoms; vasodepressor: blood pressure reduction > 50 mm Hg or > 30 mm Hg with symptoms like dizziness, vertigo or syncope; cardioinhibitory: pause > 3"; mixed: cardioinhibitory with blood pressure reduction > 30 mm Hg after atropine. Carotid sinus massage gave all informations in the supine position in 14 (12%) patients, after passive tilt in 67 (57%), after 5 minutes of tilt in 30 (26%), and after return to supine in 6 (5%). The responses were: 13 (8%) borderline vasodepressor, 32 (19%) vasodepressor, 2 (1%) cardioinhibitory, 70 (42%) mixed, 50 (30%) negative. Positive responses were more frequent in patients over 45 years (90% versus 43%). In the control group only 3 (15%) positive responses were elicited (2 borderline vasodepressor, and 1 vasodepressor, all in subjects over 45). This protocol for carotid sinus massage evidenced positive responses in 70% of patients with syncope without cardiovascular and neurological disease; cardioinhibitory responses are rare (2%); positive responses are more frequent in patients over 45 years; the protocol specificity was 85%.

Treatment efficacy for idiopathic recurrent pregnancy loss - a systematic review and meta-analyses.

PubMed

Rasmark Roepke, Emma; Hellgren, Margareta; Hjertberg, Ragnhild; Blomqvist, Lennart; Matthiesen, Leif; Henic, Emir; Lalitkumar, Sujata; Strandell, Annika

2018-03-30

Medical treatment of women with idiopathic recurrent pregnancy loss is controversial. The objective was to assess the effects of different treatments on live birth rates and complications in women with unexplained recurrent pregnancy loss. We searched MEDLINE, Embase and the Cochrane Library, and identified 1415 publications. This systematic review included 21 randomized controlled trials regarding acetylsalicylic acid, low-molecular-weight heparin, progesterone, intravenous immunoglobulin or leukocyte immune therapy in women with three or more consecutive miscarriages of unknown cause. The study quality was assessed and data was extracted independently by at least two authors. No significant difference in live birth rate was found when acetylsalicylic acid was compared with low-molecular-weight heparin or with placebo. Meta-analyses of low-molecular-weight heparin vs. control found no significant differences in live birth rate [risk ratio (RR) 1.47, 95% CI 0.83-2.61]. Treatment with progesterone starting in the luteal phase seemed effective in increasing live birth rate (RR 1.18, 95% CI 1.09-1.27) but not when started after conception. Intravenous immunoglobulin showed no effect on live birth rate compared with placebo (RR 1.07, 95% CI 0.91-1.26). Paternal immunization compared with autologous immunization showed a significant difference in outcome (RR 1.8, 95% CI 1.34-2.41), although the studies were small and at high risk of bias. The literature does not allow advice on any specific treatment for idiopathic recurrent pregnancy loss, with the exception of progesterone starting from ovulation. We suggest that any treatment for recurrent pregnancy loss should be used within the context of a randomized controlled trial. © 2018 Nordic Federation of Societies of Obstetrics and Gynecology.

Resistance of uterine radial artery blood flow was correlated with peripheral blood NK cell fraction and improved with low molecular weight heparin therapy in women with unexplained recurrent pregnancy loss.

PubMed

Koo, Hwa Seon; Kwak-Kim, Joanne; Yi, Hyun Jeong; Ahn, Hyun Kyong; Park, Chan Woo; Cha, Sun Hwa; Kang, Inn Soo; Yang, Kwang Moon

2015-02-01

To investigate whether peripheral blood natural killer (pbNK) cell levels are associated with uterine blood flow, and low molecular weight heparin (LMWH) treatment is effective to improve uterine blood flow in women with decreased uterine blood flow and unexplained recurrent pregnancy loss (RPL). This was a prospective controlled study. Study population included 33 pregnant women (between 5 and 7 weeks gestation) with ≥ 2 RPL and controls were 47 healthy pregnant women. pbNK cell fractions (CD3(-)/56(+)/16(+)) of peripheral blood mononuclear cells were measured by flow cytometry. Uterine color-pulsed Doppler ultrasound was performed to evaluate uterine radial artery resistance index (URa-RI). In RPL women with elevated URa-RI (≥ 0.5), LMWH (ranges 40-60 mg/day) was administered subcutaneously daily and URa-RI was reassessed 1 week later. Pregnancy outcome was analyzed at 12 weeks gestation. URa-RI was significantly higher in pregnant women with RPL than controls (0.60 ± 0.14 versus 0.54 ± 0.12, P = 0.039). In pregnant women with RPL, pbNK cell fractions displayed a positive correlation with URa-RI (Pearson's r = 0.429, P = 0.013). URa-RI was significantly decreased 1 week after LMWH treatment as compared to that of pretreatment (pretreatment RI: 0.65 ± 0.11 versus post-treatment RI: 0.56 ± 0.13, P = 0.011). Pregnancy outcome of RPL women with LMWH treatment was not different from that of pregnant controls (73.3% versus 85.0%, P = NS). Increased pbNK cells are associated with decreased uterine radial artery blood flow. LMWH treatment effectively decreases URa-RI with improved pregnancy outcome in women with RPLs and elevated URa-RI. A larger scale study is needed to verify these findings. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Anti-Ma2 Paraneoplastic Encephalitis in Association with Recurrent Cervical Cancer

PubMed Central

Messersmith, Wells; Behbakht, Kian

2014-01-01

Background Paraneoplastic neurological syndromes are rare, and although they are frequently associated with gynecological malignancies, cervical cancer is a rare cause. The symptoms of anti-Ma2 encephalitis are diverse and often present prior to the diagnosis of malignancy. Case Report We report a case of a 37-year-old woman with a history of cervical cancer presenting with unexplained weight gain and vertical supranuclear gaze palsy. Magnetic resonance imaging of the brain revealed lesions within the bilateral hypothalami and midbrain. Anti-Ma2 antibodies were eventually found in the serum, prompting a search for malignancy. Recurrent metastatic cervical cancer was found in the retroperitoneal lymph nodes. Conclusions This is the first report of cervical cancer in association with anti-Ma2 encephalitis, and highlights the need for a high degree of suspicion in patients with a cancer history presenting with neurological symptoms. The symptoms associated with anti-Ma2 encephalitis are diverse and typically precede the diagnosis of cancer in patients, and should trigger a search for an underlying malignancy. PMID:25045381

Association of genetic variants in the 3'UTR of HLA-G with Recurrent Pregnancy Loss.

PubMed

Amodio, Giada; Canti, Valentina; Maggio, Luana; Rosa, Susanna; Castiglioni, Maria Teresa; Rovere-Querini, Patrizia; Gregori, Silvia

2016-10-01

Human Leukocyte Antigen (HLA)-G is involved in reprogramming immune responses at fetal-maternal interface during pregnancy. We evaluated the genetic diversity of the 3' Un-Translated Region (UTR) of HLA-G, previously associated with HLA-G mRNA post-transcriptional regulation, in women with unexplained Recurrent Pregnancy Loss (RPL), with 2 pregnancy losses (RPL-2, n=28), or 3 or more pregnancy losses (RPL-3, n=24), and in 30 women with a history of successful pregnancy. Results showed in RPL-2, but not in RPL-3, women compared to controls: i) higher frequency of the 14bp Ins allele, in single and in double copy; ii) significantly lower frequency of DelG/X genotype, iii) reduced frequency of the UTR-2, and UTR-3 haplotypes; iv) higher frequencies of the UTR-5, UTR-7, and UTR-8 haplotypes. This pilot study supports the relevance of performing 3'UTR HLA-G genetic screening, not limited to a specific polymorphism, but considering the extended haplotypes, as a possible predictor of pregnancy outcome. Copyright © 2016. Published by Elsevier Inc.

Atypical presentation of paroxysmal nocturnal hemoglobinuria treated by eculizumab

PubMed Central

Quinquenel, Anne; Maestraggi, Quentin; Lecoq-Lafon, Carinne; Régis, Peffault de Latour; Delmer, Alain; Servettaz, Amélie

2017-01-01

Abstract Rationale: Paroxysmal nocturnal hemoglobinuria (PNH) is a nonmalignant acquired hematopoietic stem cell disease, which can be revealed by hemolytic anemia, thromboembolism, or bonemarrow failure. Thrombosis can occur at any site, but coronary thrombosis is extremely rare. Controlled trials have demonstrated that eculizimab, an inhibitor of the terminal complement cascade, was able to reduce both hemolysis and thrombosis, but its efficacy in cases of PNH with coronary thrombosis is unknown. Patient concerns and diagnoses: We report herein the unusual case of a 73-year-old patient presenting with recurrent coronary syndromes without associated stenosis, fever, marked inflammatory syndrome, and anemia, leading to a delayed diagnosis of PNH. Intervention and outcomes: Eculizumab allowed the resolution of fever and inflammation, and prevented further thromboembolism. Lessons: This case emphasizes the importance of performing aflow cytometry test for PNH in front of unusual or unexplained recurrent thromboses. Thromboses, as observed in our case, may be associated with fever and marked inflammation. This case also provides useful information on eculizumab ability to prevent further thromboembolism in PNH patients with a medical history of arterial thrombosis. PMID:28328837

Plasma homocysteine and vitamin B12 serum levels, red blood cell folate concentrations, C677T methylenetetrahydrofolate reductase gene mutation and risk of recurrent miscarriage: a case-control study in Spain.

PubMed

Creus, Montserrat; Deulofeu, Ramon; Peñarrubia, Joana; Carmona, Francisco; Balasch, Juan

2013-03-01

Hyperhomocysteinemia and methylenetetrahydrofolate reductase (MTHFR) gene mutation have been postulated as a possible cause of recurrent miscarriage (RM). There is a wide variation in the prevalence of MTHFR polymorphisms and homocysteine (Hcy) plasma levels among populations around the world. The present study was undertaken to investigate the possible association between hyperhomocysteinemia and its causative genetic or acquired factors and RM in Catalonia, a Mediterranean region in Spain. Sixty consecutive patients with ≥ 3 unexplained RM and 30 healthy control women having at least one child but no previous miscarriage were included. Plasma Hcy levels, MTHFR gene mutation, red blood cell (RBC) folate and vitamin B12 serum levels were measured in all subjects. No significant differences were observed neither in plasma Hcy levels, RBC folate and vitamin B12 serum levels nor in the prevalence of homozygous and heterozygous MTHFR gene mutation between the two groups studied. In the present study RM is not associated with hyperhomocysteinemia, and/or the MTHFR gene mutation.

Relationship between sperm aneuploidy, sperm DNA integrity, chromatin packaging, traditional semen parameters, and recurrent pregnancy loss.

PubMed

Zidi-Jrah, Ines; Hajlaoui, Amani; Mougou-Zerelli, Soumaya; Kammoun, Molka; Meniaoui, Imene; Sallem, Amira; Brahem, Sonia; Fekih, Meriem; Bibi, Mohammed; Saad, Ali; Ibala-Romdhane, Samira

2016-01-01

To study the possible relationship between sperm aneuploidy, sperm DNA integrity, chromatin packaging, traditional semen parameters, and recurrent pregnancy loss (RPL). Descriptive study. University-affiliated tertiary teaching. A total of 22 couples with history of RPL and 20 fertile men. Semen samples from case and control men were examined for differences in semen parameters, DNA fragmentation, chromatin condensation, and sperm aneuploidy. Sperm DNA and chromatin integrity and sperm aneuploidy. Sperm progressive motility (30.2% vs. 51.5%) was significantly lower and abnormal morphology (74.8% vs. 54.2%) was significantly higher in the RPL group versus the control group, respectively. The percentage of fragmented DNA was significantly increased in the RPL group (17.1% vs. 10.2%) as well as the rate of spermatozoa with nuclear chromatin decondensation (23.6% vs. 11.8%). There was a significantly higher sperm aneuploidy rate among the RPL group as well. The increase in abnormal sperm parameters, sperm DNA fragmentation, nuclear chromatin decondensation, and sperm aneuploidy suggest possible causes of unexplained RPL. Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

77-year-old female with syncope.

PubMed

Abdelsalam, Mahmoud A; Geske, Jeffrey B

2017-02-15

A 77-year-old female was referred for evaluation of an episode of syncope while eating breakfast. There was no history of fall, syncope, prodrome, dyspnoea, chest discomfort or palpitations. Medical history was notable for hyperlipidaemia and treated hypertension. Blood pressure was 140/90 mm Hg, pulse 85  beats per minute (BPM). No murmurs were present on cardiac examination. ECG revealed normal sinus rhythm with left ventricular (LV) hypertrophy (see online supplementary figure S1). Holter monitor demonstrated rare premature ventricular complexes (<1% of beats), without heart block or ventricular tachycardia. Transthoracic echocardiogram is shown in figure 1. Which of the following is the explanation for the flow indicated by the yellow arrow? Aortic stenosisCoronary artery flow, indicative of coronary fistulaHypertrophic cardiomyopathy with apical pouchHypertensive heart diseaseMitral stenosis. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Vertigo/dizziness in pediatric emergency department: Five years' experience.

PubMed

Raucci, Umberto; Vanacore, Nicola; Paolino, Maria Chiara; Silenzi, Romina; Mariani, Rosanna; Urbano, Antonella; Reale, Antonino; Villa, Maria Pia; Parisi, Pasquale

2016-05-01

Vertigo/Dizziness in childhood is not a rare cause of visits to the emergency department (ED). We analyzed a selected group with vertigo/dizziness to identify signs and symptoms that may help to guide the diagnostic approach and management. A total of 616 children admitted for vertigo to the ED over a five-year period were retrospectively reviewed. Their medical history, clinical characteristics, laboratory and neuroimaging tests, final diagnoses and management were analyzed. Migraine and syncope were the most frequent causes. Two patients were affected by life-threatening cardiac syncope, while structural life-threatening central nervous system diseases were found in 15 patients, none of whom presented with vertigo as an isolated clinical finding. Most cases of vertigo/dizziness in childhood that consist mainly of migraine and syncope are of benign origin. The prompt identification of neurological or cardiological signs or symptoms associated with vertigo in children is mandatory to rule out life-threatening conditions. © International Headache Society 2015.

Simulation training for medical emergencies in the dental setting using an inexpensive software application.

PubMed

Kishimoto, N; Mukai, N; Honda, Y; Hirata, Y; Tanaka, M; Momota, Y

2017-11-09

Every dental provider needs to be educated about medical emergencies to provide safe dental care. Simulation training is available with simulators such as advanced life support manikins and robot patients. However, the purchase and development costs of these simulators are high. We have developed a simulation training course on medical emergencies using an inexpensive software application. The purpose of this study was to evaluate the educational effectiveness of this course. Fifty-one dental providers participated in this study from December 2014 to March 2015. Medical simulation software was used to simulate a patient's vital signs. We evaluated participants' ability to diagnose and treat vasovagal syncope or anaphylaxis with an evaluation sheet and conducted a questionnaire before and after the scenario-based simulation training. The median evaluation sheet score for vasovagal syncope increased significantly from 7/9 before to 9/9 after simulation training. The median score for anaphylaxis also increased significantly from 8/12 to 12/12 (P < .01). For the item "I can treat vasovagal syncope/anaphylaxis adequately," the percentage responding "Strongly agree" or "Agree" increased from 14% to 56% for vasovagal syncope and from 6% to 42% for anaphylaxis with simulation training. This simulation course improved participants' ability to diagnose and treat medical emergencies and improved their confidence. This course can be offered inexpensively using a software application. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Standardized reporting guidelines for emergency department syncope risk-stratification research.

PubMed

Sun, Benjamin C; Thiruganasambandamoorthy, Venkatesh; Cruz, Jeffrey Dela

2012-06-01

There is increasing research interest in the risk stratification of emergency department (ED) syncope patients. A major barrier to comparing and synthesizing existing research is wide variation in the conduct and reporting of studies. The authors wanted to create standardized reporting guidelines for ED syncope risk-stratification research using an expert consensus process. In that pursuit, a panel of syncope researchers was convened and a literature review was performed to identify candidate reporting guideline elements. Candidate elements were grouped into four sections: eligibility criteria, outcomes, electrocardiogram (ECG) findings, and predictors. A two-round, modified Delphi consensus process was conducted using an Internet-based survey application. In the first round, candidate elements were rated on a five-point Likert scale. In the second round, panelists rerated items after receiving information about group ratings from the first round. Items that were rated by >80% of the panelists at the two highest levels of the Likert scale were included in the final guidelines. There were 24 panelists from eight countries who represented five clinical specialties. The panel identified an initial set of 183 candidate elements. After two survey rounds, the final reporting guidelines included 92 items that achieved >80% consensus. These included 10 items for study eligibility, 23 items for outcomes, nine items for ECG abnormalities, and 50 items for candidate predictors. Adherence to these guidelines should facilitate comparison of future research in this area. © 2012 by the Society for Academic Emergency Medicine.

A Novel Approach to Proactive Primary Care-Based Case Finding and Multidisciplinary Management of Falls, Syncope, and Dizziness in a One-Stop Service: Preliminary Results.

PubMed

Parry, Steve W; Hill, Harry; Lawson, Joanna; Lawson, Nick; Green, David; Trundle, Heidi; McNaught, Judith; Strassheim, Victoria; Caldwell, Alma; Mayland, Richard; Earley, Phillip; McMeekin, Peter

2016-11-01

National and international evidence and guidelines on falls prevention and management in community-dwelling elderly adults recommend that falls services should be multifactorial and their interventions multicomponent. The way that individuals are identified as having had or being at risk of falls in order to take advantage of such services is far less clear. A novel multidisciplinary, multifactorial falls, syncope, and dizziness service model was designed with enhanced case ascertainment through proactive, primary care-based screening (of individual case notes of individuals aged ≥60) for individual fall risk factors. The service model identified 4,039 individuals, of whom 2,232 had significant gait and balance abnormalities according to senior physiotherapist assessment. Significant numbers of individuals with new diagnoses ranging from cognitive impairment to Parkinson's disease to urgent indications for a pacemaker were discovered. More than 600 individuals were found who were at high risk of osteoporosis according to World Health Association Fracture Risk Assessment Tool score, 179 with benign positional paroxysmal vertigo and 50 with atrial fibrillation. Through such screening and this approach, Comprehensive Geriatric Assessment Plus (Plus falls, syncope and dizziness expertise), unmet need was targeted on a scale far outside the numbers seen in clinical trials. Further work is needed to determine whether this approach translates into fewer falls and decreases in syncope and dizziness. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

Recurrent elevated liver transaminases and acute liver failure in two siblings with novel bi-allelic mutations of NBAS.

PubMed

Regateiro, Frederico S; Belkaya, Serkan; Neves, Nélson; Ferreira, Sandra; Silvestre, Paula; Lemos, Sónia; Venâncio, Margarida; Casanova, Jean-Laurent; Gonçalves, Isabel; Jouanguy, Emmanuelle; Diogo, Luísa

2017-08-01

Acute liver failure (ALF) in children can be life-threatening. Although many causes are known, ALF remains unexplained in about half of the cases. Recently, bi-allelic mutations in NBAS were reported to underlie recurrent episodes of elevated liver transaminases (ELT) and ALF in the context of diverse extrahepatic phenotypes. We here describe two sisters, born to non-consanguineous Portuguese parents, who had short stature and presented with recurrent episodes of severe ELT triggered by febrile respiratory viral infections since early childhood. Patient 1 had mild facial dysmorphism and died during the second ELT crisis at 3-11/12 years of age. Patient 2, currently 9 years old, had multiple episodes of ELT (>30), twice with ALF, often accompanied by extensive urticaria and facial angioedema. Whole-exome and Sanger sequencing revealed that both patients carried previously undescribed compound heterozygous mutations of NBAS (NM_015909.3): c.680A > C (p.His227Pro), affecting an evolutionarily conserved residue, and c.1749G > A (p.Trp583*), causing a premature stop codon. Both mutations are predicted to be highly damaging. The parents and two younger siblings are healthy and heterozygous for one or another mutant allele. The multiplex kindred reported herein expands the genotypic and phenotypic spectrum of this recently described clinical syndrome due to autosomal recessive NBAS deficiency. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Recurrent somnolence in a 17-month-old infant: late-onset ornithine transcarbamylase (OTC) deficiency due to the novel hemizygous mutation c.535C > T (p.Leu179Phe).

PubMed

Fantur, Michaela; Karall, Daniela; Scholl-Buergi, Sabine; Häberle, Johannes; Rauchenzauner, Markus; Fruehwirth, Martin

2013-01-01

Herein, we describe a case of a now 28-month-old boy who presented at the age of 17 months with four episodes of recurrent vomiting and somnolence during a period of four months with increasing severity. A comprehensive clinical and metabolic evaluation revealed normal blood pH and blood glucose, normal cerebral computed tomography and electroencephalogram but an elevated plasma ammonia concentration, which raised the suspicion of a urea cycle disorder. The combination of elevated urinary orotic acid and plasma glutamine with normal citrulline suggested the diagnosis of ornithine transcarbamylase (OTC) deficiency, which was confirmed by molecular genetic testing revealing the novel hemizygous mutation c.535C > T (p.Leu179Phe) of the OTC gene. After restitution of anabolism by administration of parenteral glucose, substitution of citrulline and detoxification of ammonia with sodium benzoate, the patient recovered rapidly and is in a stable metabolic and neurological state since then. This case underlines that the diagnosis of a urea cycle defect should be considered in the differential diagnosis of recurrent idiopathic vomiting in combination with unexplained neurological symptoms also beyond the neonatal period due to the possibility of mild or atypical late-onset presentation (e.g. OTC deficiency in hemizygous males). Copyright © 2012 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.

Increased circulating cell-derived microparticle count is associated with recurrent implantation failure after IVF and embryo transfer.

PubMed

Martínez-Zamora, M Angeles; Tàssies, Dolors; Reverter, Juan Carlos; Creus, Montserrat; Casals, Gemma; Cívico, Salvadora; Carmona, Francisco; Balasch, Juan

2016-08-01

Cell-derived microparticles (cMPs) are small membrane vesicles that are released from many different cell types in response to cellular activation or apoptosis. Elevated cMP counts have been found in almost all thrombotic diseases and pregnancy wastage, such as recurrent spontaneous abortion and in a number of conditions associated with inflammation, cellular activation and angiogenesis. cMP count was investigated in patients experiencing unexplained recurrent implantation failure (RIF). The study group was composed of 30 women diagnosed with RIF (RIF group). The first control group (IVF group) (n = 30) comprised patients undergoing a first successful IVF cycle. The second control group (FER group) included 30 healthy women who had at least one child born at term and no history of infertility or obstetric complications. cMP count was significantly higher in the RIF group compared with the IVF and FER groups (P < 0.05 and P < 0.01, respectively) (RIF group: 15.8 ± 6.2 nM phosphatidylserine equivalent [PS eq]; IVF group: 10.9 ± 5.3 nM PS eq; FER group: 9.6 ± 4.0 nM PS eq). No statistical difference was found in cMP count between the IVF and FER groups. Increased cMP count is, therefore, associated with RIF after IVF and embryo transfer. Copyright © 2016. Published by Elsevier Ltd.

Bundle-branch reentry ventricular tachycardia after transcatheter aortic valve replacement

PubMed Central

de la Rosa Riestra, Adriana; Rubio Caballero, José Amador; Freites Estévez, Alfonso; Alonso Belló, Javier; Botas Rodríguez, Javier

2016-01-01

An 83-year-old male suffering from severe symptomatic aortic valve stenosis received an implant of a biological aortic prosthesis through the femoral artery without complications. Seven days after dischargement he experienced a syncope. The patient was wearing an ECG holter monitor that day, which showed a wide QRS complex tachycardia of 300 beats per minute. The electrophysiological study revealed a bundle-branch reentry ventricular tachycardia as the cause of the syncope. Radio-frequency was applied on the right-bundle branch. Twelve months later, the patient has remained asymptomatic. PMID:27134443

[Atypical sinus node dysfunction. Usefulness of implantable Holter. A case report].

PubMed

Martí Almor, J; Delclòs Urgell, J; Bruguera Cortada, J

2001-12-01

We present an 84 year-old female patient with repeated syncopes/presyncopes in the last nine years. All diagnosis tests were negative, including ECG, 24-hour Holter, tilt table test and EP study. Therefore, a subcutaneous insertable loop recorder was implanted (Reveal). The recording of three episodes showed the association of presyncope with the onset of atrial fibrilation and, in two syncopes, with an atrial pause between AF episodes. Probably an abnormal prolonged sinus node recovery time (more than 6 s) allowed AF to restart before the sinus rhythm.

Chiari type I malformation, syncope, headache, hypoglycemia and hepatic steatosis in an 8-year old girl: a causal association?

PubMed Central

Tarani, Luigi; Del Balzo, Francesca; Costantino, Francesco; Properzi, Enrico; D’Eufemia, Patrizia; Liberati, Natascia; Spalice, Alberto

2010-01-01

Chiari type I malformation (CMI) is a congenital hindbrain anomaly characterized by downward displacement of the cerebellar tonsils through the foramen magnum. Chiari type I malformation often presents with a complex clinical picture and can be sporadic or linked to a variety of genetic conditions. We report on a girl in whom Chiari type I malformation was associated with hypoglycemia, headache, vertigo, syncope and hepatic steatosis. We hypothesize that these symptoms are primarily a consequence of Chiari type I malformation. PMID:21589844

Safety evaluation of laninamivir octanoate hydrate through analysis of adverse events reported during early post-marketing phase vigilance.

PubMed

Nakano, Takashi; Okumura, Akihisa; Tanabe, Takuya; Niwa, Shimpei; Fukushima, Masato; Yonemochi, Rie; Eda, Hisano; Tsutsumi, Hiroyuki

2013-06-01

Abnormal behavior and delirium are common in children with influenza. While abnormal behavior and delirium are considered to be associated with influenza encephalopathy, an increased risk of such neuropsychiatric symptoms in patients receiving neuraminidase inhibitor treatment is suspected. Laninamivir octanoate hydrate, recently approved in Japan, is a long-acting neuraminidase inhibitor. It is important to establish a safety profile for laninamivir early, based on post-marketing experiences. Spontaneous safety reports collected in the early post-marketing phase vigilance were analyzed. Adverse events of interest such as abnormal behavior/delirium, dizziness/vertigo, respiratory disorders, shock/syncope, and any other serious events were intensively reviewed by the Safety Evaluation Committee. Abnormal behavior/delirium was a frequently reported event. Almost all the reported cases were considered to be due to influenza and not laninamivir. There were 32 cases of abnormal behavior/delirium that could lead to dangerous accidents, and these were observed more frequently in males and teenagers. Syncope probably related to the act of inhalation per se of laninamivir was reported during this survey. This safety review revealed that the safety profile of laninamivir for abnormal behavior/delirium and syncope was similar to that of other neuraminidase inhibitors. As stated in the labeling, teenage patients inhaling laninamivir should remain under constant parental supervision for at least 2 days and should be closely monitored for behavioral changes to prevent serious accidents associated with abnormal behavior/delirium. Furthermore, to avoid syncope because of inhalation, patients should be instructed to inhale in a relaxed sitting position.

Bimanual tapping of a syncopated rhythm reveals hemispheric preferences for relative movement frequencies.

PubMed

Pflug, Anja; Gompf, Florian; Kell, Christian Alexander

2017-08-01

In bimanual multifrequency tapping, right-handers commonly use the right hand to tap the relatively higher rate and the left hand to tap the relatively lower rate. This could be due to hemispheric specializations for the processing of relative frequencies. An extension of the double-filtering-by-frequency theory to motor control proposes a left hemispheric specialization for the control of relatively high and a right hemispheric specialization for the control of relatively low tapping rates. We investigated timing variability and rhythmic accentuation in right handers tapping mono- and multifrequent bimanual rhythms to test the predictions of the double-filtering-by-frequency theory. Yet, hemispheric specializations for the processing of relative tapping rates could be masked by a left hemispheric dominance for the control of known sequences. Tapping was thus either performed in an overlearned quadruple meter (tap of the slow rhythm on the first auditory beat) or in a syncopated quadruple meter (tap of the slow rhythm on the fourth auditory beat). Independent of syncopation, the right hand outperformed the left hand in timing accuracy for fast tapping. A left hand timing benefit for slow tapping rates as predicted by the double-filtering-by-frequency theory was only found in the syncopated tapping group. This suggests a right hemisphere preference for the control of slow tapping rates when rhythms are not overlearned. Error rates indicate that overlearned rhythms represent hierarchically structured meters that are controlled by a single timer that could potentially reside in the left hemisphere. Copyright © 2017 Elsevier B.V. All rights reserved.

A Case of ADEM Mimicking Cerebral Adrenoleukodystrophy Based on Supratentorial MRI Findings

PubMed Central

BEYAZAL, Mehmet; ÜNAL, Özkan; YILMAZ, Sanem; BORA, Aydın

2014-01-01

A 9-year-old male admitted for syncope also had the complains of pain and numbness in his legs and frequent falling down. There was a history of upper respiratory tract infection 10 days before. On neurologic examination, paraparesia and fall a sleep were identified. On magnetic resonance imaging, the symetric signal increases were seen in biparieto-occipital white matter intented to corpus callosum at T2-weighted sequences and cytotoxic edema was seen at diffusion-weighted images. Heterogeneous contrast enhancement was seen on these areas. In addition, at the C7-Th5 vertebrae levels, spinal cord had diffuse increased signal intensity and contrast enhancement. Acute disseminated encephalomyelitis was thought based on clinical and radiological findings. Steroid therapy was started. Significant improvement was shown after treatment. On 2-year follow-up, there was no recurrence. In conclusion, it must be kept in mind that acute disseminated encephalomyelitis can rarely present with biparieto-occipital involvement which extends to corpus callosum and can mimic adrenoleukodystrophy. For the differential diagnosis butterfly glioma, tumefactive demyelinating lesions or multiple sclerosis should be considered. PMID:28360602

[Loss of capture by myocardial ischemia: A case report].

PubMed

Sonou, A; Adjagba, P M; Hounkponou, M; Codjo, L; Houéhanou-Sonou, C; Assani, S; Yessoufou, T; Sacca, J; Houénassi, M

2017-02-01

We report the case of a patient with pacemaker who presented chest pain during exercise followed by fainting. He has a history of arterial hypertension and diabetes. The initial examination was normal; the ventricular stimulation threshold was 1.125 volts (V) and cardiac enzymes were normal. Stress test has reproduced chest pain followed by loss of pacemaker capture and asystole. Coronary angiography showed a tight stenosis of the proximal anterior interventricular artery dilated by a drug-eluting stent. The control of stress test was normal. A stent thrombosis eight days later led to an acute coronary syndrome with recurrent syncope due to the loss of ventricular capture. The ventricular pacing threshold was then 2.25V. After revascularization and stabilization of the patient's clinical status, this threshold returned to 1.125V. This clinic case has confirmed that coronary artery disease could increase pacing threshold. It also highlights the usefulness of automatic capture algorithms in coronary patients. The stress test cannot only help to detect coronary artery disease but also allows the optimization of programming the pacemaker. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Stenting of the right ventricular outflow tract in 2 dogs for palliation of dysplastic pulmonary valve stenosis and right-to-left intracardiac shunting defects.

PubMed

Scansen, Brian A; Kent, Agnieszka M; Cheatham, Sharon L; Cheatham, John P; Cheatham, John D

2014-09-01

Two dogs with severe dysplastic pulmonary valve stenosis and right-to-left shunting defects (patent foramen ovale, perimembranous ventricular septal defect) underwent palliative stenting of the right ventricular outflow tract and pulmonary valve annulus using balloon expandable stents. One dog received 2 over-lapping bare metal stents placed 7 months apart; the other received a single covered stent. Both procedures were considered technically successful with a reduction in the transpulmonary valve pressure gradient from 202 to 90 mmHg in 1 dog and from 168 to 95 mmHg in the other. Clinical signs of exercise intolerance and syncope were temporarily resolved in both dogs. However, progressive right ventricular concentric hypertrophy, recurrent stenosis, and erythrocytosis were observed over the subsequent 6 months leading to poor long-term outcomes. Stenting of the right ventricular outflow tract is feasible in dogs with severe dysplastic pulmonary valve stenosis, though further study and optimization of the procedure is required. Copyright © 2014 Elsevier B.V. All rights reserved.

Rupture of a pacemaker lead during the course of infective endocarditis.

PubMed

Akgüllü, Çağdaş; Eryılmaz, Ufuk; Kurtoğlu, Tünay; Özpelit, Ebru

2013-01-01

A 23-year-old male who had a VDDR pacemaker implanted seven years ago due to sick sinus syndrome and recurrent syncope episodes was admitted with symptoms of dyspnea, fever, and tachycardia, which were present for a few days. He was suspected to be suffering from pneumonia and underwent computed tomography scanning of the thorax, which revealed widespread infiltration in the lung parenchyma and pulmonary emboli. Transthoracic echocardiography revealed an extremely mobile echogenic structure in the right atrium, which was determined to be the free portion of a ruptured pacemaker lead. There was an overlying thrombus and/or vegetation-like organized soft tissue within the right ventricle around the lead component. In this article, the rupture of a permanent pacemaker lead, which complicated the course of infective endocarditis associated with pulmonary embolism and pneumonia is reported. We hypothesize that the underlying mechanism for the rupture is soft tissue entrapment within the right ventricle. Unfortunately, this rare and life-threatening situation led to the death of our patient after the surgical removal of the device and its components.

Wolff-Parkinson-white syndrome mimics a conduction disease.

PubMed

Marrakchi, S; Kammoun, I; Kachboura, S

2014-01-01

Background. It is important to recognise Wolff-Parkinson-White (WPW) syndrome in electrocardiograms (ECG), as it may mimic ischaemic heart disease, ventricular hypertrophy, and bundle branch block. Recognising WPW syndrome allows for risk stratification, the identification of associated conditions, and the institution of appropriate management. Objective. The present case showed that electrophysiological study is indicated in patients with abnormal ECG and syncope. Case Report. A 40-year-old man with Wolff-Parkinson-White syndrome was presented to emergency with syncope. A baseline ECG was a complete right branch block and posterior left hemiblock. He was admitted to the cardiac care unit for pacemaker implantation. The atypical figure of complete right branch block and posterior left hemiblock was thought to be a "false positive" of conduction abnormality. But the long anterograde refractory period of the both accessory pathway and atrioventricular conduction may cause difficulty in diagnosing Wolff-Parkinson-White syndrome, Conclusion. A Wolff-Parkinson-White Syndrome may mimic a conduction disease. No reliable algorithm exists for making an ECG diagnosis of a preexcitation syndrome with conduction disorders. This can lead to diagnostic and therapeutic dilemmas in the context of syncope.

Medically Unexplained Symptoms

MedlinePlus

WRIISC War Related Illness and Injury Study Center Office of Public Health Department of Veterans Affairs MEDICALLY UNEXPLAINED SYMPTOMS A RESOURCE FOR VETERANS, SERVICE MEMBERS, AND THEIR FAMILIES Medically Unexplained ...

Working out the interstitial and syncopic nature of the human psyche: on the analysis of verbal data.

PubMed

Roth, Wolff-Michael

2014-09-01

Psychology studies the human mind and its development. Although it is often recognized that the human mind needs to be understood as a temporal (developmental) phenomenon between past and future and at the interstices between the idealities of pure Self and Other, the analytic methods interpretive researchers use tend to reify ahistorical and solipsist conceptions of the human being. In this article, I provide examples of an approach to the analysis of verbal data that immediately gets us to the interstitial and syncopic nature of the human psyche.

PROMISE: first-trimester progesterone therapy in women with a history of unexplained recurrent miscarriages - a randomised, double-blind, placebo-controlled, international multicentre trial and economic evaluation.

PubMed

Coomarasamy, Arri; Williams, Helen; Truchanowicz, Ewa; Seed, Paul T; Small, Rachel; Quenby, Siobhan; Gupta, Pratima; Dawood, Feroza; Koot, Yvonne E; Atik, Ruth Bender; Bloemenkamp, Kitty Wm; Brady, Rebecca; Briley, Annette; Cavallaro, Rebecca; Cheong, Ying C; Chu, Justin; Eapen, Abey; Essex, Holly; Ewies, Ayman; Hoek, Annemieke; Kaaijk, Eugenie M; Koks, Carolien A; Li, Tin-Chiu; MacLean, Marjory; Mol, Ben W; Moore, Judith; Parrott, Steve; Ross, Jackie A; Sharpe, Lisa; Stewart, Jane; Trépel, Dominic; Vaithilingam, Nirmala; Farquharson, Roy G; Kilby, Mark David; Khalaf, Yacoub; Goddijn, Mariëtte; Regan, Lesley; Rai, Rajendra

2016-05-01

Progesterone is essential to maintain a healthy pregnancy. Guidance from the Royal College of Obstetricians and Gynaecologists and a Cochrane review called for a definitive trial to test whether or not progesterone therapy in the first trimester could reduce the risk of miscarriage in women with a history of unexplained recurrent miscarriage (RM). The PROMISE trial was conducted to answer this question. A concurrent cost-effectiveness analysis was conducted. A randomised, double-blind, placebo-controlled, international multicentre study, with economic evaluation, conducted in hospital settings across the UK (36 sites) and in the Netherlands (nine sites). Women with unexplained RM (three or more first-trimester losses), aged between 18 and 39 years at randomisation, conceiving naturally and giving informed consent, received either micronised progesterone (Utrogestan(®), Besins Healthcare) at a dose of 400 mg (two vaginal capsules of 200 mg) or placebo vaginal capsules twice daily, administered vaginally from soon after a positive urinary pregnancy test (and no later than 6 weeks of gestation) until 12 completed weeks of gestation (or earlier if the pregnancy ended before 12 weeks). Live birth beyond 24 completed weeks of gestation (primary outcome), clinical pregnancy at 6-8 weeks, ongoing pregnancy at 12 weeks, miscarriage, gestation at delivery, neonatal survival at 28 days of life, congenital abnormalities and resource use. Participants were randomised after confirmation of pregnancy. Randomisation was performed online via a secure internet facility. Data were collected on four occasions of outcome assessment after randomisation, up to 28 days after birth. A total of 1568 participants were screened for eligibility. Of the 836 women randomised between 2010 and 2013, 404 received progesterone and 432 received placebo. The baseline data (age, body mass index, maternal ethnicity, smoking status and parity) of the participants were comparable in the two arms of the trial. The follow-up rate to primary outcome was 826 out of 836 (98.8%). The live birth rate in the progesterone group was 65.8% (262/398) and in the placebo group it was 63.3% (271/428), giving a relative risk of 1.04 (95% confidence interval 0.94 to 1.15; p = 0.45). There was no evidence of a significant difference between the groups for any of the secondary outcomes. Economic analysis suggested a favourable incremental cost-effectiveness ratio for decision-making but wide confidence intervals indicated a high level of uncertainty in the health benefits. Additional sensitivity analysis suggested the probability that progesterone would fall within the National Institute for Health and Care Excellence's threshold of £20,000-30,000 per quality-adjusted life-year as between 0.7145 and 0.7341. There is no evidence that first-trimester progesterone therapy improves outcomes in women with a history of unexplained RM. This study did not explore the effect of treatment with other progesterone preparations or treatment during the luteal phase of the menstrual cycle. Future research could explore the efficacy of progesterone supplementation administered during the luteal phase of the menstrual cycle in women attempting natural conception despite a history of RM. Current Controlled Trials ISRCTN92644181; EudraCT 2009-011208-42; Research Ethics Committee 09/H1208/44. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 41. See the NIHR Journals Library website for further project information.

A practical approach to the prevention of miscarriage: part 5--antiphospholipid syndrome as a cause of spontaneous abortion.

PubMed

Check, J H

2011-01-01

To describe the diagnosis and treatment of antiphospholipid syndrome as it relates to spontaneous abortion. The relative importance of performing tests of antiphospholipid antibodies that prolong the partial thromboplastin time and other autoantibodies against phospholipids measured by ELISA are discussed. The most important diagnostic tests are the lupus anticoagulant, anticardiolipin antibody and antiphosphatidyl serine. Low molecular weight heparin and low dose aspirin are the two most important therapies. Women with recurrent miscarriages or even an unexplained miscarriage especially after ten weeks (but sometimes even early first trimester) or a history of thrombosis or intrauterine growth restriction and maybe preeclampsia are candidates for anticoagulant therapy, especially with the presence of significant levels of the lupus anticoagulant or anticardiolipin or antiphosphatidyl serine antibodies (> 40 pl units/ml).

Disseminated Penicilliosis, Recurrent Bacteremic Nontyphoidal Salmonellosis, and Burkholderiosis Associated with Acquired Immunodeficiency Due to Autoantibody against Gamma Interferon ▿

PubMed Central

Tang, Bone Siu-Fai; Chan, Jasper Fuk-Woo; Chen, Min; Tsang, Owen Tak-Yin; Mok, M. Y.; Lai, Raymond Wai-Man; Lee, Rodney; Que, Tak-Lun; Tse, Herman; Li, Iris Wai-Sum; To, Kelvin Kai-Wang; Cheng, Vincent Chi-Chung; Chan, Eric Yuk-Tat; Zheng, Bojian; Yuen, Kwok-Yung

2010-01-01

Acquired immunodeficiency due to autoantibody against gamma interferon has recently been associated with opportunistic nontuberculous mycobacteriosis, especially among Southeast Asians. We report another 8 cases, all except one apparently immunocompetent hosts who suffered from concomitant or sequential infections by other intracellular pathogens causing penicilliosis, extraintestinal nontyphoidal salmonellosis, and burkholderiosis. The only case with an underlying immunodeficiency syndrome had systemic lupus erythematosus that was quiescent throughout the multiple infective episodes. Eight out of 10 (80.0%) patients with serological evidence of penicilliosis, 5 out of 7 (71.4%) with culture-positive extraintestinal nontyphoidal salmonellosis, 5 out of 28 (17.9%) with serological evidence of melioidosis, and 7 out of 13 (53.8%) with culture-positive nontuberculous mycobacteriosis possessed autoantibody against gamma interferon, whereas only 1 out of 100 patients with systemic lupus erythematosus did. Our study represents the first and largest case series linking this emerging immunodeficiency syndrome with these atypical infections in apparently immunocompetent hosts. Thus, we advocate that any patient with unexplained recurrent or polymicrobial infections due to these intracellular pathogens should be screened for acquired immunodeficiency due to autoantibody against gamma interferon. PMID:20445006

The medically unexplained revisited.

PubMed

Eriksen, Thor Eirik; Kirkengen, Anna Luise; Vetlesen, Arne Johan

2013-08-01

Medicine is facing wide-ranging challenges concerning the so-called medically unexplained disorders. The epidemiology is confusing, different medical specialties claim ownership of their unexplained territory and the unexplained conditions are themselves promoted through a highly complicated and sophisticated use of language. Confronting the outcome, i.e. numerous medical acronyms, we reflect upon principles of systematizing, contextual and social considerations and ways of thinking about these phenomena. Finally we address what we consider to be crucial dimensions concerning the landscape of unexplained "matters"; fatigued being, pain-full being and dys-ordered being, all expressive momentums of an aesthetic of resistance.

Prevalence and Spectrum of Large Deletions or Duplications in the Major Long QT Syndrome-Susceptibility Genes and Implications for Long QT Syndrome Genetic Testing

PubMed Central

Tester, David J.; Benton, Amber J.; Train, Laura; Deal, Barbara; Baudhuin, Linnea M.; Ackerman, Michael J.

2010-01-01

Long QT Syndrome (LQTS) is a cardiac channelopathy associated with syncope, seizures, and sudden death. Approximately 75% of LQTS is due to mutations in genes encoding for three cardiac ion channel alpha-subunits (LQT1-3). However, traditional mutational analyses have limited detection capabilities for atypical mutations such as large gene rearrangements. Here, we set out to determine the prevalence and spectrum of large deletions/duplications in the major LQTS-susceptibility genes among unrelated patients who were mutation-negative following point mutation analysis of LQT1-12-susceptibility genes. Forty-two unrelated clinically strong LQTS patients were analyzed using multiplex ligation-dependent probe amplification (MLPA), a quantitative fluorescent technique for detecting multiple exon deletions and duplications. The SALSA-MLPA LQTS Kit from MRC-Holland was used to analyze the three major LQTS-associated genes: KCNQ1, KCNH2, and SCN5A and the two minor genes: KCNE1 and KCNE2. Overall, 2 gene rearrangements were found in 2/42 (4.8%, CI, 1.7–11%) unrelated patients. A deletion of KCNQ1 exon 3 was identified in a 10 year-old Caucasian boy with a QTc of 660 milliseconds (ms), a personal history of exercise-induced syncope, and a family history of syncope. A deletion of KCNQ1 exon 7 was identified in a 17 year-old Caucasian girl with a QTc of 480 ms, a personal history of exercise-induced syncope, and a family history of sudden cardiac death. In conclusion, since nearly 5% of patients with genetically elusive LQTS had large genomic rearrangements involving the canonical LQTS-susceptibility genes, reflex genetic testing to investigate genomic rearrangements may be of clinical value. PMID:20920651

[Determination of prognostic value of the OESIL risk score at 6 months in a Colombian cohort with syncope evaluated in the emergency department; first Latin American experience].

PubMed

Díaz-Tribaldos, Diana Carolina; Mora, Guillermo; Olaya, Alejandro; Marín, Jorge; Sierra Matamoros, Fabio

2017-07-14

To establish the prognostic value, with sensitivity, specificity, positive predictive value, and negative predictive value for the OESIL syncope risk score to predict the presentation of severe outcomes (death, invasive interventions, and readmission) after 6 months of observation in adults who consulted the emergency department due to syncope. Observational, prospective, and multicentre study with enrolment of subjects older than 18 years, who consulted in the emergency department due to syncope. A record was mad of the demographic and clinical information of all patients. The OESIL risk score was calculated, and severe patient outcomes were followed up during a 6 month period using telephone contact. A total of 161 patients met the inclusion criteria and were followed up for 6 months. A score above or equal to 2 in the risk score, classified as high risk, was present in 72% of the patients. The characteristics of the risk score to predict the combined outcome of mortality, invasive interventions, and readmission for a score above or equal to 2 were 75.7, 30.5, 43.1, and 64.4% for sensitivity, specificity, positive predictive value, and negative predictive value, respectively. A score above or equal to 2 in the OESIL risk score applied in Colombian population was of limited use to predict the studied severe outcomes. This score will be unable to discriminate between patients that benefit of early admission and further clinical studies. Copyright © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.

Clinical outcomes according to symptom presentation in patients with acute myocardial infarction: Results from the FAST-MI 2010 registry.

PubMed

Puymirat, Etienne; Aissaoui, Nadia; Bonello, Laurent; Cayla, Guillaume; Labèque, Jean-Noel; Nallet, Olivier; Motreff, Pascal; Varenne, Olivier; Schiele, François; Ferrières, Jean; Simon, Tabassome; Danchin, Nicolas

2017-12-01

Atypical clinical presentation in acute myocardial infarction (AMI) patients is not uncommon; most studies suggest that it is associated with unfavorable prognosis. Long-term clinical impact differs according to predominant symptom presentation (typical chest pain, atypical chest pain, syncope, cardiac arrest, or dyspnea) in AMI patients. FAST-MI 2010, a nationwide French registry, included 4169 patients with AMI in 213 centers at the end of 2010 (76% of active centers). Demographics, medical history, hospital management, and outcomes were compared according to predominant symptom presentation. Typical chest pain with no other symptom was reported in 3020 patients (68% in STEMI patients, 76% in NSTEMI patients). Atypical chest pain, dyspnea, syncope, and cardiac arrest were reported in 11%, 11%, 5%, and 1%, respectively. Patients with atypical clinical presentation had a higher cardiovascular risk profile and received fewer medications and a less invasive strategy. Using Cox multivariate analysis, atypical chest pain was not associated with higher death rate at 3 years (HR: 0.96, 95% CI: 0.69-1.33, P = 0.78), whereas cardiac arrest (HR: 2.44, 95% CI: 1.00-5.97, P = 0.05), syncope (HR: 1.70, 95% CI: 1.18-2.46, P = 0.005), and dyspnea (HR: 1.66, 95% CI: 1.31-2.10, P < 0.001) were associated with higher long-term mortality compared with patients with typical isolated chest pain. Similar trends were observed in STEMI and NSTEMI populations. Atypical clinical presentation is observed in about 20% of AMI patients. Cardiac arrest, dyspnea, and syncope represent independent predictors of long-term mortality in STEMI and NSTEMI populations. © 2017 Wiley Periodicals, Inc.

Distinct pattern of Th17/Treg cells in pregnant women with a history of unexplained recurrent spontaneous abortion.

PubMed

Qian, Jinfeng; Zhang, Na; Lin, Jing; Wang, Caiyan; Pan, Xinyao; Chen, Lanting; Li, Dajin; Wang, Ling

2018-05-13

The aim of the current study was to determine the pattern of immune cells and related functional molecules in peripheral blood and at the maternal-fetal interface in women with unexplained recurrent spontaneous abortion (URSA). In part I, 155 women were included and divided into four groups: non-pregnant controls with no history of URSA (NPCs), pregnant controls with no history of URSA (PCs), non-pregnant women with a history of URSA (NPUs), and pregnant women with a history of URSA (PUs). Venous blood samples were collected and analyzed. In part II, 35 subjects with URSA and 40 subjects in the early stage of normal pregnancy who chose to undergo an abortion were recruited. Samples of the decidua were collected, and the proportion of immune cells and the expression of related molecules were evaluated. Peripheral regulatory T cells (Treg cells) increased in PCs compared to NPCs, but in women with URSA the flux of Treg cells disappeared when pregnancy occurred. Levels of interleukin-10 (IL-10), cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), and IL-17 and the ratio of Th17/Treg cells in peripheral blood remained stable among the four groups. At the maternal-fetal interface, the percentage of Treg cells, the level of CTLA-4 of CD4 + CD25 + CD127 lo cells and CD4 + Foxp3 + cells were significantly lower in women with URSA compared to controls, respectively. Levels of transforming growth factor-β1 (TGF-β1) mRNA and protein in the decidua significantly decreased in URSA while levels of IL-6 and tumor necrosis factor-ɑ (TNF-ɑ) and the Th17/Treg ratio significantly increased. In conclusion, peripheral Treg cells did not increase in pregnant women with URSA. The decrease in Treg cells and levels of CTLA-4 and TGF-β1 and as well as the increase in levels of IL-6 and TNF-ɑ, and the Th17/Treg ratio at the maternal-fetal interface might contribute to inappropriate maternal-fetal immune tolerance in URSA.

Echocardiography and cardiac MRI in mutation-negative hypertrophic cardiomyopathy in an older patient: a case defining the need for ICD.

PubMed

Rodriguez, Fatima; Degnan, Kathleen O; Seidman, Christine E; Mangion, Judy R

2014-08-01

We report the case of a 67-year-old man with hypertrophic cardiomyopathy who presented for a second opinion about implantable cardio-defibrillator (ICD) placement after a witnessed syncopal episode. Despite his older age, being mutation-negative, and having a maximal septal thickness of 2.2 cm on echocardiography, he demonstrated rapid progression of myocardial fibrosis on cardiac MRI, correlating to ventricular tachyarrhythmias and syncope. We review the role of echocardiography and cardiac MRI in optimizing medical care for such patients who may not otherwise meet criteria for an ICD placement or further interventions. © 2014, Wiley Periodicals, Inc.

Neurocardiovascular Instability and Cognition

PubMed Central

O’Callaghan, Susan; Kenny, Rose Anne

2016-01-01

Neurocardiovascular instability (NCVI) refers to abnormal neural control of the cardiovascular system affecting blood pressure and heart rate behavior. Autonomic dysfunction and impaired cerebral autoregulation in aging contribute to this phenomenon characterized by hypotension and bradyarrhythmia. Ultimately, this increases the risk of falls and syncope in older people. NCVI is common in patients with neurodegenerative disorders including dementia. This review discusses the various syndromes that characterize NCVI icluding hypotension, carotid sinus hypersensitivity, postprandial hypotension and vasovagal syncope and how they may contribute to the aetiology of cognitive decline. Conversely, they may also be a consequence of a common neurodegenerative process. Regardless, recognition of their association is paramount in optimizing management of these patients. PMID:27505017

An Unusual Cause of Carbon Monoxide Poisoning: Narghile Smoking

PubMed Central

Ateş, Alpay; Arikan, Müge; Özgök, Ayşegül

2016-01-01

Patient: Male, 27 Final Diagnosis: Carbon monoxide poisoning Symptoms: Dizziness • nausea • Syncope Medication: — Clinical Procedure: O2 treatment Specialty: Anesthesiology Objective: Challenging differential diagnosis Background: Carbon monoxide (CO) poisoning is commonly seen during the winter season in Turkey due to use of charcoal stoves and water heaters, but narghile smoking is a rare cause of CO poisoning. Case Report: In this paper, we report a CO poisoning case caused by narghile smoking. The patient was admitted to the ED with nausea, dizziness, vertigo, and syncope. Conclusions: The diagnosis of CO poisoning depends on suspicious anamnesis. The major treatment of CO poisoning is oxygen supply. PMID:27618983

Delaying Orthostatic Syncope With Mental Challenge

NASA Astrophysics Data System (ADS)

Goswami, Nandu; Roessler, Andreas; Hinghofer-Szalkay, Helmut; Montani, Jean-Pierre; Steptoe, Andrew

2012-07-01

At orthostatic vasovagal syncope there appears to be a sudden withdrawl of sympathetic activity. As mental challenge activates the sympathetic system, we hypothesized that doing mental arithmetic in volunteers driven to the end point of their cardiovascular stability may delay the onset of orthostatic syncope. We investigated this in healthy male subjects. Each subject underwent a head up tilt (HUT) + graded lower body negative pressure (LBNP) up to presyncope session (control) to determine the orthostatic tolerance time, OTT (Time from HUT commencement to development of presyncopal symptoms/signs). Once the tolerance time was known, a randomized crossover protocol was used: either 1) Repeat HUT + LBNP to ensure reproducibility of repeated run or 2) HUT + LBNP run but with added mental challenge (two min before the expected presyncope time). Test protocols were separated by two weeks. Our studies on five male test subjects indicate that mental challenge improves orthostatic tolerance significantly. Additional mental loading could be a useful countermeasure to alleviate the orthostatic responses of persons, particularly in those with histories of dizziness on standing up, or to alleviate hypotension that frequently occurs during hemodialysis or on return to earth from the spaceflight environment of microgravity.

The use of external event monitoring (web-loop) in the elucidation of symptoms associated with arrhythmias in a general population

PubMed Central

Epifanio, Hindalis Ballesteros; Katz, Marcelo; Borges, Melania Aparecida; Corrêa, Alessandra da Graça; Cintra, Fátima Dumas; Grinberg, Rodrigo Leandro; Ludovice, Ana Cristina Pinotti Pedro; Valdigem, Bruno Pereira; da Silva, Nilton José Carneiro; Fenelon, Guilherme

2014-01-01

Objective To correlate arrhythmic symptoms with the presence of significant arrhythmias through the external event monitoring (web-loop). Methods Between January and December 2011, the web-loop was connected to 112 patients (46% of them were women, mean age 52±21 years old). Specific arrhythmic symptoms were defined as palpitations, pre-syncope and syncope observed during the monitoring. Supraventricular tachycardia, atrial flutter or fibrillation, ventricular tachycardia, pauses greater than 2 seconds or advanced atrioventricular block were classified as significant arrhythmia. The association between symptoms and significant arrhythmias were analyzed. Results The web-loop recorded arrhythmic symptoms in 74 (66%) patients. Of these, in only 14 (19%) patients the association between symptoms and significant cardiac arrhythmia was detected. Moreover, significant arrhythmia was found in 11 (9.8%) asymptomatic patients. There was no association between presence of major symptoms and significant cardiac arrhythmia (OR=0.57, CI95%: 0.21-1.57; p=0.23). Conclusion We found no association between major symptoms and significant cardiac arrhythmia in patients submitted to event recorder monitoring. Event loop recorder was useful to elucidate cases of palpitations and syncope in symptomatic patients. PMID:25295448

Exercise-induced syncope in a 22-year-old man.

PubMed

Yeo, Colin; Tan, Vern Hsen; Wong, Kelvin Ck

2017-04-01

A 22-year-old man was referred to us for syncope during a game of Captain's ball. There was no prodrome. His friends did not notice any ictal movements. He was otherwise well prior to passing out. He was not taking any medications or supplements. He was not usually physically active, but was otherwise well with no significant medical history. This is his first episode of syncope. There was no history of cardiac arrest or seizures. There is no family history of premature sudden cardiac death.Physical examination was normal. ECG at rest demonstrated sinus rhythm with corrected QT interval of 400 ms. Echocardiography revealed a structurally normal heart. Holter monitoring was normal. Treadmill exercise stress test demonstrated the following rhythm on figure 1 during stage 4 Bruce protocol. Stress test was terminated in view of sustained arrhythmia as illustrated. He felt light-headed during the period, but otherwise felt that he could carry on with the exercise. ECG during recovery was unremarkable. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Delta space plot analysis of cardiovascular coupling in vasovagal syncope during orthostatic challenge.

PubMed

Reulecke, S; Charleston-Villalobos, S; Voss, A; Gonzalez-Camarena, R; Gaitan-Gonzalez, M; Gonzalez-Hermosillo, J; Hernandez-Pacheco, G; Aljama-Corrales, T

2016-08-01

In this work, a graphical method to study cardiovascular coupling, called delta space plot analysis (DSPA), was introduced. The graphical representation is susceptible to be parameterized in shape and orientation. The usefulness of this technique was studied on cardiovascular data from patients with vasovagal syncope (VVS) and from controls. The study included 15 female patients diagnosed with VVS and 11 age-matched healthy female subjects. All subjects were enrolled in a head-up tilt (HUT) test, breathing normally, including 5 minutes of supine position (baseline) and 18 minutes of 70° orthostatic phase. The DSPA parameters were obtained at different times during the HUT test, i.e., at baseline, early (first 5 min) and late (10-15 min) orthostatic phases. In baseline there were no considerable differences between female controls and female patients. During the late orthostatic phase, parameters from DSPA showed highly significantly (p=0.000003) reduced cardiovascular coupling in patients. Findings indicated a loss of control on cardiovascular coupling in female patients susceptible to vasovagal syncope during orthostatic challenge. In addition, this study provided promising results for a new graphical method to investigate cardiovascular coupling.

Wolff-Parkinson-White Syndrome Mimics a Conduction Disease

PubMed Central

Marrakchi, S.; Kammoun, I.; Kachboura, S.

2014-01-01

Background. It is important to recognise Wolff-Parkinson-White (WPW) syndrome in electrocardiograms (ECG), as it may mimic ischaemic heart disease, ventricular hypertrophy, and bundle branch block. Recognising WPW syndrome allows for risk stratification, the identification of associated conditions, and the institution of appropriate management. Objective. The present case showed that electrophysiological study is indicated in patients with abnormal ECG and syncope. Case Report. A 40-year-old man with Wolff-Parkinson-White syndrome was presented to emergency with syncope. A baseline ECG was a complete right branch block and posterior left hemiblock. He was admitted to the cardiac care unit for pacemaker implantation. The atypical figure of complete right branch block and posterior left hemiblock was thought to be a “false positive” of conduction abnormality. But the long anterograde refractory period of the both accessory pathway and atrioventricular conduction may cause difficulty in diagnosing Wolff-Parkinson-White syndrome, Conclusion. A Wolff-Parkinson-White Syndrome may mimic a conduction disease. No reliable algorithm exists for making an ECG diagnosis of a preexcitation syndrome with conduction disorders. This can lead to diagnostic and therapeutic dilemmas in the context of syncope. PMID:25114686

Effects of long-term vasodilator therapy in patients with carotid sinus hypersensitivity.

PubMed

Brignole, M; Menozzi, C; Gaggioli, G; Musso, G; Foglia-Manzillo, G; Mascioli, G; Fradella, G; Bottoni, N; Mureddu, R

1998-08-01

In patients affected by carotid sinus hypersensitivity, long-term vasodilator therapy might increase the risk of syncopal episodes by reducing systolic blood pressure and venous return to the heart. Thirty-two patients (mean age 73 +/- 9 years; 20 men) who met all the following criteria were included: (1) one or more episodes of syncope occurring during long-term (>6 months) treatment with angiotensin-converting enzyme inhibitors, long-acting nitrates, calcium antagonists, or a combination of these; (2) a positive response to carotid sinus massage, defined as the reproduction of spontaneous syncope in the presence of ventricular asystole > or =3 seconds or a fall in systolic blood pressure > or =50 mm Hg; (3) negative workup for other causes of syncope. The patients were randomly assigned to continue or to discontinue use of vasodilators; carotid sinus massage was repeated 2 weeks after randomization. By the end of the study period, the baseline values of systolic blood pressure were significantly different between the 2 groups of patients both in supine (P=.01) and upright (P=.03) positions. Syncope had been induced by carotid sinus massage in 81% of patients in the "on-vasodilator" group and in 62% of patients in the "off-vasodilator" group (P=.21). The cardioinhibitory reflex was of similar magnitude in the 2 groups, being found in 50% of the patients in each group, with a maximum ventricular pause of 7.1 +/- 2.7 and 6.7 +/- 1.8 seconds, respectively. The percentage decrease of blood pressure did not differ between the 2 groups, even if, in absolute values, the baseline difference of blood pressure roughly persisted for the duration of the test. In consequence of that, the rise of blood pressure to similar values was delayed approximately 30 seconds in the "on-vasodilator" group and took more than 2 minutes to return to baseline values. In patients affected by carotid sinus hypersensitivity, chronic vasodilator therapy does not have a direct effect on carotid sinus reflexivity, although the delayed recovery of pretest blood pressure values could indirectly potentiate the severity of the clinical manifestations of the syndrome. The persistence of hypotension for a longer time after the end of the massage suggests that vasodilators cause an impairment of compensatory mechanisms.

[The relevance of junctional rhythm during neurocardiogenic reaction provoked by tilt testing].

PubMed

Zyśko, Dorota; Gajek, Jacek; Agrawal, Anil Kumar; Rudnicki, Jerzy

2012-01-01

During neurocardiogenic reaction provoked by tilt testing (TT), different arrhythmias such as sinus bradycardia, sinus arrest, atrioventricular block or junctional rhythm or beats (JR) may occur. The characteristics of the JR during neurocardiogenic reaction have not yet been systematically assessed. It is not known whether the presence of JR during neurocardiogenic reaction is related to clinical characteristics of syncopal patients or the outcome of TT. To assess whether clinical outcome of TT and clinical data are related to the presence of JR during TT. The study group consisted of 532 patients aged 43.3 ± 18.2 years with positive TT, divided into four groups on the basis of the presence of JR and/or a ventricular pause (VP) during neurocardiogenic reaction: group VP(-)/JR(+) - JR present and VP absent, group VP(+)/JR(+) - both JR and VP present, group VP(+)/JR(-) - JR absent and VP present, and group VP(-)/JR(-) - both JR and VP absent. The control group consisted of 53 patients with no history of syncope or presyncope, including 46 patients with negative TT and seven patients with false positive TT. Total loss of consciousness during TT occurred in group VP(-)/JR(+) less frequently than in groups VP(+)/JR(+) and VP(+)/JR(-), and more frequently than in group VP(-)/JR(-) (80% vs 96% vs 94% vs 62%; p 〈 0.05 for both comparisons). Group VP(-)/JR(+) was significantly younger than group VP(-)/JR(-) (37.3 ± 16.3 years vs 45.8 ± 18.9 years; p 〈 0.05) and had a lower number of syncopal events than group VP(+)/JR(+) and VP(+)/JR(-) (median [IQ]: 2.5 (1-6) vs 4 (2-12) and 4 (2-10), respectively; p 〈 0.05) and lower rate of traumatic injuries than group VP(+)/JR(+) and VP(+)/JR(-) (22% vs 45% and 39%, respectively; p 〈 0.05). Logistic regression analysis revealed that the presence of JR was associated with younger age, male gender, history of blood-instrumentation-injection phobia and higher number of syncopal spells in medical history. The ROC curve analysis revealed that a junctional rate of no more than 49 bpm was related to the total loss of consciousness during TT (p 〈 0.05). 1. JR frequently occurs during positive TT and in no subjects with negative TT. 2. Among patients with JR, two groups may be chosen on the basis of a VP occurrence, and these groups differ in respect to clinical characteristics and TT outcome. 3. Relatively rapid JR without VP is related to consciousness preservation during neurocardiogenic reaction at TT and fewer syncopal spells as well as syncope associated with injury in the past. 4. In patients with JR and VP, the JR is slower, of shorter duration, and more frequently single or pairs of junctional beats occur, which indicates high parasympathetic activity, whereas relatively rapid and stable JR may be the symptom of simultaneously increased sympathetic and parasympathetic activity.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Jin, K.; Gill, T.J. III; Ho, H.N.

The association between HLA sharing and recurrent spontaneous abortion (RSA) was tested in 123 couples and the association between HLA sharing, and the outcome of treatment for unexplained infertility by in vitro fertilization (IVF) was tested in 76 couples, by using a new shared-allele test in order to identify more precisely the region of the major histocompatibility complex (MHC) influencing these reproductive defects. The shared-allele test circumvents the problem of rare alleles at HLA loci and at the same time provides a substantial gain in power over the simple {chi}{sup 2} test. Two statistical methods, a corrected homogeneity test andmore » a bootstrap approach, were developed to compare the allele frequencies at each of the HLA-A, HLA-B, HLA-DR, and HLA-DQ loci; they were not statistically different amount the three patient groups and the control group. There was a significant excess of HLA-DR sharing in couples with RSA and a significant excess of HLA-DQ sharing in couples with unexplained infertility who failed treatment by IVF. These findings indicate that genes located in different parts of the class II region of the MHC affect different aspects of reproduction and strongly suggest that the sharing of HLA antigens per se is not the mechanism involved in the reproductive defects. The segment of the MHC that has genes affecting reproduction also has genes associated with different autoimmune diseases, and this juxtaposition may explain the association between reproductive defects and autoimmune diseases. 58 refs., 1 fig., 7 tabs.« less

Obstructive Sleep Apnea: An Unusual Cause of Hemorrhagic Stroke.

PubMed

Pawar, Nilesh H; O'Riordan, Jennifer A; Malik, Preeti; Vasanwala, Farhad F

2017-09-27

Stroke is one of the most common causes of mortality and morbidity worldwide. Hemorrhagic stroke comprises 10-20% of strokes. Here, we present a case report of hemorrhagic stroke that may have been secondary to untreated Obstructive Sleep Apnea (OSA) in a young man with no other cardiovascular risk factors or features of metabolic syndrome. A 32-year-old man was admitted for hemorrhagic stroke. An initial thorough workup for the etiology of stroke was inconclusive. Eventually, a polysomnography was done, which demonstrated OSA suggesting that untreated OSA may have contributed to his stroke. OSA may cause hemorrhagic stroke by nocturnal blood pressure surge. So, all physicians should consider doing polysomnography for unexplained hemorrhagic stroke or in patients at risk. Diagnosing and treating OSA would be critical in preventing hemorrhagic stroke and its recurrences.

Development and validation of a dual sensing scheme to improve accuracy of bradycardia and pause detection in an insertable cardiac monitor.

PubMed

Passman, Rod S; Rogers, John D; Sarkar, Shantanu; Reiland, Jerry; Reisfeld, Erin; Koehler, Jodi; Mittal, Suneet

2017-07-01

Undersensing of premature ventricular beats and low-amplitude R waves are primary causes for inappropriate bradycardia and pause detections in insertable cardiac monitors (ICMs). The purpose of this study was to develop and validate an enhanced algorithm to reduce inappropriately detected bradycardia and pause episodes. Independent data sets to develop and validate the enhanced algorithm were derived from a database of ICM-detected bradycardia and pause episodes in de-identified patients monitored for unexplained syncope. The original algorithm uses an auto-adjusting sensitivity threshold for R-wave sensing to detect tachycardia and avoid T-wave oversensing. In the enhanced algorithm, a second sensing threshold is used with a long blanking and fixed lower sensitivity threshold, looking for evidence of undersensed signals. Data reported includes percent change in appropriate and inappropriate bradycardia and pause detections as well as changes in episode detection sensitivity and positive predictive value with the enhanced algorithm. The validation data set, from 663 consecutive patients, consisted of 4904 (161 patients) bradycardia and 2582 (133 patients) pause episodes, of which 2976 (61%) and 996 (39%) were appropriately detected bradycardia and pause episodes. The enhanced algorithm reduced inappropriate bradycardia and pause episodes by 95% and 47%, respectively, with 1.7% and 0.6% reduction in appropriate episodes, respectively. The average episode positive predictive value improved by 62% (P < .001) for bradycardia detection and by 26% (P < .001) for pause detection, with an average relative sensitivity of 95% (P < .001) and 99% (P = .5), respectively. The enhanced dual sense algorithm for bradycardia and pause detection in ICMs substantially reduced inappropriate episode detection with a minimal reduction in true episode detection. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Recurrent pregnancy loss: what is the impact of consecutive versus non-consecutive losses?

PubMed

Egerup, P; Kolte, A M; Larsen, E C; Krog, M; Nielsen, H S; Christiansen, O B

2016-11-01

Is there a different prognostic impact for consecutive and non-consecutive early pregnancy losses in women with secondary recurrent pregnancy loss (RPL)? Only consecutive early pregnancy losses after the last birth have a statistically significant negative prognostic impact in women with secondary RPL. The risk of a new pregnancy loss increases with the number of previous pregnancy losses in patients with RPL. Second trimester losses seem to exhibit a stronger negative impact than early losses. It is unknown whether the sequence of pregnancy losses plays a role for the prognosis in patients with a prior birth. This retrospective cohort study of pregnancy outcome in patients with unexplained secondary RPL included in three previously published, Danish double-blinded placebo-controlled trials of intravenous immunoglobulin (IvIg) conducted from 1991 to 2014. No other treatments were given. Patients with documented explained pregnancy losses (ectopic pregnancies and aneuploid miscarriages) were excluded. Of the 168 patients included in the trials, 127 had secondary RPL and experienced a subsequent live birth or unexplained pregnancy loss in the first pregnancy after giving informed consent to participate in the trials (the index pregnancy). Data analyzed by multivariate analysis included the independent variables age, the number of early pregnancy losses before and after the last birth, respectively and a second trimester pregnancy loss before or after the last birth, respectively. The outcome variable was unexplained loss in the index pregnancy. In patients with secondary RPL, both a late and each early loss before the last birth did not significantly influence the risk of a new pregnancy loss in the index pregnancy: incidence rate ratio (IRR) 1.31 (95% CI 0.62-2.77) and IRR 0.88 (95% CI 0.70-1.11), respectively. In contrast, the impact on risk of pregnancy loss conferred by a late and by each early pregnancy loss occurring after the birth was significant: IRR 2.15 (95% CI 1.57-2.94, P < 0.0001) and IRR 1.14 (95% CI 1.04-1.24, P = 0.002), respectively. Of the patients, 48% were treated with IvIg, which could influence the results. However, allocation to IvIg was random and prognostic variables were equally distributed in IvIg and placebo-treated patients. A birth in women with secondary RPL eradicates the negative prognostic impact of previous pregnancy losses and this finding is important for our understanding of the pathogenesis. It indicates that only consecutive pregnancy losses should count in the definition of RPL. There was no particular funding for this study. The authors declare that there is no conflict of interest. Not applicable for two of the included randomized controlled trials. For the last trial: Clinical.Gov NCT00722475. © The Author 2016. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Analysis of Wind Tunnel Polar Replicates Using the Modern Design of Experiments

NASA Technical Reports Server (NTRS)

Deloach, Richard; Micol, John R.

2010-01-01

The role of variance in a Modern Design of Experiments analysis of wind tunnel data is reviewed, with distinctions made between explained and unexplained variance. The partitioning of unexplained variance into systematic and random components is illustrated, with examples of the elusive systematic component provided for various types of real-world tests. The importance of detecting and defending against systematic unexplained variance in wind tunnel testing is discussed, and the random and systematic components of unexplained variance are examined for a representative wind tunnel data set acquired in a test in which a missile is used as a test article. The adverse impact of correlated (non-independent) experimental errors is described, and recommendations are offered for replication strategies that facilitate the quantification of random and systematic unexplained variance.

[Orthostatic postural tachycardia: study of 8 patients].

PubMed

Santiago Pérez, S; Ferrer Gila, T

1998-02-07

The occurrence of syncopal episodes is a very frequent event. In the absence of a structural systemic or cardiac disease, syncope is resulting of an anomalous cardiovascular response neurally mediated by the autonomic nervous system. It is the final common manifestation of different abnormal mechanisms and is frequently precipitated by orthostatism. Orthostatic intolerance syndrome refers to the development of symptoms during the upright posture that disappear in supine position. Tachycardia may be one of the clinical features of the syndrome. During orthostatic stress a hyperadrenergic response, with maintained increment of heart rate and associated symptoms, is developed. Changes in blood pressure may be diverse and in some cases hypotension and syncope occurs. Eight patients with symptoms of orthostatic intolerance who underwent autonomic evaluation and were diagnosed from postural tachycardia are presented. In all the cases an abnormal increment of heart rate during tilting was found and it was associated to hyperadrenergic symptoms. Evidence of restricted sympathetic impairment was observed in six cases with distal reduction of sudomotor function and abnormal adrenergic response during Valsalva manoeuvre. Symptoms disappeared or mostly subsided with pharmacological (amitriptyline in one case, phenobarbital in another one and non-cardioselective beta-blockers in six patients) and non-pharmacological treatment. In further examinations heart rate and blood pressure were normal.

Alteration of gene expression profiling including GPR174 and GNG2 is associated with vasovagal syncope.

PubMed

Huang, Yu-Juan; Zhou, Zai-wei; Xu, Miao; Ma, Qing-wen; Yan, Jing-bin; Wang, Jian-yi; Zhang, Quo-qin; Huang, Min; Bao, Liming

2015-03-01

Vasovagal syncope (VVS) causes accidental harm for susceptible patients. However, pathophysiology of this disorder remains largely unknown. In an effort to understanding of molecular mechanism for VVS, genome-wide gene expression profiling analyses were performed on VVS patients at syncope state. A total of 66 Type 1 VVS child patients and the same number healthy controls were enrolled in this study. Peripheral blood RNAs were isolated from all subjects, of which 10 RNA samples were randomly selected from each groups for gene expression profile analysis using Gene ST 1.0 arrays (Affymetrix). The results revealed that 103 genes were differently expressed between the patients and controls. Significantly, two G-proteins related genes, GPR174 and GNG2 that have not been related to VVS were among the differently expressed genes. The microarray results were confirmed by qRT-PCR in all the tested individuals. Ingenuity pathway analysis and gene ontology annotation study showed that the differently expressed genes are associated with stress response and apoptosis, suggesting that the alteration of some gene expression including G-proteins related genes is associated with VVS. This study provides new insight into the molecular mechanism of VVS and would be helpful to further identify new molecular biomarkers for the disease.

Celiac disease serum markers and recurrent pregnancy loss.

PubMed

Sharshiner, Rita; Romero, Stephanie T; Bardsley, Tyler R; Branch, D Ware; Silver, Robert M

2013-12-01

Celiac disease has been associated with numerous unfavorable health outcomes, including pregnancy complications such as infertility, preterm birth, and preeclampsia. However, the association between celiac disease and recurrent pregnancy loss (RPL) remains uncertain. Our purpose was to compare serum markers of celiac disease in women with and without RPL. Therefore, we performed a case-control study of 116 women with unexplained recurrent pregnancy loss and 116 age-matched controls. Maternal sera were analyzed for immunoglobulin A (IgA) and immunoglobulin G (IgG) tissue transglutaminase (tTG) antibodies and endomysial (EM) antibodies. Groups were similar with regard to age, race and ethnicity, and BMI. One case and one control tested positive (≥20 Units) for IgA tTG antibodies and mean levels of IgA tTG antibodies were similar in cases and controls (5.5±2.86 versus 6.0±12.45; p=0.16). No cases or controls were positive for IgG tTG antibodies. However, cases had higher levels of IgG tTG antibody compared with controls (4.0±2.40 versus 3.3±1.30; p=0.0064). One subject (a control) tested positive for IgA EM antibodies and no subjects tested positive for IgG EM antibodies. In conclusion, positive results for tTG and EM antibodies were similar in women with and without RPL. Given these results, testing for occult celiac disease is not recommended in the evaluation of women with idiopathic RPL. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Race and fall risk: data from the National Health and Aging Trends Study (NHATS)

PubMed Central

Sun, Daniel Q.; Huang, Jin; Varadhan, Ravi; Agrawal, Yuri

2016-01-01

Objectives: the objective of this study was to explore whether race-based difference in fall risk may be mediated by environmental and physical performance risk factors. Methods: using data from a nationally representative longitudinal survey of 7,609 community-dwelling participants in the National Health and Aging Trends Study (NHATS), we evaluated whether racial differences in fall risk may be explained by physical performance level (measured by the Short Physical Performance Battery), mobility disability, physical activity level and likelihood of living alone. Multivariate Poisson regression and mediation models were used in analyses. Results: in whites and blacks, the annual incidence of ‘any fall’ was 33.8 and 27.1%, respectively, and the annual incidence of ‘recurrent falls’ was 15.5 and 12.3%, respectively. Compared with whites, blacks had relative risks of 0.7 (95% confidence interval 0.6–0.8) and 0.6 (0.5–0.8) for sustaining any fall and recurrent falls, respectively, in adjusted analyses. Blacks had poorer performance on the SPPB (P < 0.001), higher levels of mobility disability (P < 0.001), similar levels of physical activity (P = 0.19) and were equally likely to live alone relative to whites (P = 0.77). Mediation analysis revealed that these risk factors collectively acted as suppressors and none of these factors accounted for the racial differences in fall risk observed. Conclusions: relative to whites, blacks were at 30 and 40% decreased risk of sustaining any fall and recurrent falls, respectively. This difference in risk remains unexplained. PMID:26764401

The balance of the immune system between HLA-G and NK cells in unexplained recurrent spontaneous abortion and polymorphisms analysis.

PubMed

Arjmand, Fateme; Ghasemi, Nasrin; Mirghanizadeh, Seyed Ali; Samadi, Morteza

2016-06-01

Human leukocyte antigen (HLA)-G is involved in immunoregulatory processes and particularly in pathogenesis of inflammatory disorders such as recurrent spontaneous abortions (RSA). The purpose of the current study was to examine whether two single nucleotide polymorphisms (SNPs) of HLA-G gene (rs1736936 and HLA-G*0105N) influence susceptibility to recurrent spontaneous abortion. Genomic DNA from 117 RSA patients and 117 normal fertile control individuals was isolated using the salted out method. The two single nucleotide polymorphisms in HLA-G gene were analyzed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Differences between the two groups were analyzed by SPSS19 software using Chi-square test. The results revealed a significant increase in HLA-G*0105N allele in the proportion of whole group of RSA women compared with fertile controls (P value = 0.015), OR (95 % CI) = 2.054 (1.798-2.347), as well as an absence of homozygosity for HLA-G*0105N in the study population. No significant difference was observed between the RSA and the fertile groups in terms of alleles and genotypes frequency of rs1736936 (P value = 0.323), OR (95 CI %) = 1.056 (0.844-1.319). The presented data suggest that the investigated HLA-G*0105N allele is potentially associated with RSA through linkage disequilibrium with other genetic elements. Meanwhile, the rs1736936 SNP do not predispose to RSA in the study population.

Association between HLA-E gene polymorphism and unexplained recurrent spontaneous abortion (RSA) in Iranian women.

PubMed

Fotoohi, Maryam; Ghasemi, Nasrin; Mirghanizadeh, Seyed Ali; Vakili, Mahmood; Samadi, Morteza

2016-07-01

Human leukocyte antigen-E (HLA-E)is a non-classical major histocompatibility complex (MHC) class I antigens which expressed on extra villous cytotrophoblast, which interacts with NKG2A, is an inhibitory receptor on natural killer (NK) cells and leading to down regulation of immune response in the maternal-fetal interface and provides maternal immune tolerance of the fetus. This study was designated to investigate the gene frequencies of E0101 and E0103 in HLA-E gene in Iranian women with recurrent spontaneous abortion (RSA). Amplification Refractory Mutation System (ARMS-PCR) technique was carried out to detect polymorphism in exon 3 of the HLA-E gene in women with RSA and controls (n=200). Differences between groups were analyzed by SPSS19 software using (2) test. There was no significant difference in the allele frequencies of the HLA-E polymorphism between RSA and fertile controls but HLA-E 0101/0103 heterozygous genotype was found to be significantly higher in RSA group (p=0.006, OR=1.73), so this genotype might confer susceptibility to RSA. Our results suggest that HLA-E 0101/0103 heterozygous genotype leads to increase of RSA risk. It seems that by genotyping of HLA-E polymorphism, we can predict the risk of RSA in infertile women.

Maternal HY-restricting HLA class II alleles are associated with poor long-term outcome in recurrent pregnancy loss after a boy.

PubMed

Kolte, Astrid Marie; Steffensen, Rudi; Christiansen, Ole Bjarne; Nielsen, Henriette Svarre

2016-11-01

Women with secondary recurrent pregnancy loss (RPL) after a boy have a reduced chance of live birth in the first pregnancy after referral if they carry HY-restricting HLA class II alleles, but long-term chance of live birth is unknown. Live birth was compared for 540 women with unexplained secondary RPL according to firstborn's sex and maternal carriage of HLA-DRB3*03:01, HLA-DQB1*05:01/02, HLA-DRB1*15, and HLA-DRB1*07. The groups were compared by Cox proportional hazard ratios. For women with at firstborn boy, maternal carriage of HY-restricting HLA class II alleles decreased chance of live birth: 0 vs 1: hazard ratio 0.75 (95% CI 0.55-1.02); 0 vs 2: HR 0.62 (0.40-0.94). Carriage of HY-restricting HLA class II alleles decreased chance of live birth only if the firstborn was a boy: boy vs girl: HR 0.72 (95% CI 0.55-0.98). Maternal carriage of HY-restricting HLA class II alleles decreases long-term chance of live birth in women with RPL after a boy. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Recurrence and variability of germline EPCAM deletions in Lynch syndrome.

PubMed

Kuiper, Roland P; Vissers, Lisenka E L M; Venkatachalam, Ramprasath; Bodmer, Danielle; Hoenselaar, Eveline; Goossens, Monique; Haufe, Aline; Kamping, Eveline; Niessen, Renée C; Hogervorst, Frans B L; Gille, Johan J P; Redeker, Bert; Tops, Carli M J; van Gijn, Marielle E; van den Ouweland, Ans M W; Rahner, Nils; Steinke, Verena; Kahl, Philip; Holinski-Feder, Elke; Morak, Monika; Kloor, Matthias; Stemmler, Susanne; Betz, Beate; Hutter, Pierre; Bunyan, David J; Syngal, Sapna; Culver, Julie O; Graham, Tracy; Chan, Tsun L; Nagtegaal, Iris D; van Krieken, J Han J M; Schackert, Hans K; Hoogerbrugge, Nicoline; van Kessel, Ad Geurts; Ligtenberg, Marjolijn J L

2011-04-01

Recently, we identified 3' end deletions in the EPCAM gene as a novel cause of Lynch syndrome. These truncating EPCAM deletions cause allele-specific epigenetic silencing of the neighboring DNA mismatch repair gene MSH2 in tissues expressing EPCAM. Here we screened a cohort of unexplained Lynch-like families for the presence of EPCAM deletions. We identified 27 novel independent MSH2-deficient families from multiple geographical origins with varying deletions all encompassing the 3' end of EPCAM, but leaving the MSH2 gene intact. Within The Netherlands and Germany, EPCAM deletions appeared to represent at least 2.8% and 1.1% of the confirmed Lynch syndrome families, respectively. MSH2 promoter methylation was observed in epithelial tissues of all deletion carriers tested, thus confirming silencing of MSH2 as the causative defect. In a total of 45 families, 19 different deletions were found, all including the last two exons and the transcription termination signal of EPCAM. All deletions appeared to originate from Alu-repeat mediated recombination events. In 17 cases regions of microhomology around the breakpoints were found, suggesting nonallelic homologous recombination as the most likely mechanism. We conclude that 3' end EPCAM deletions are a recurrent cause of Lynch syndrome, which should be implemented in routine Lynch syndrome diagnostics. © 2011 Wiley-Liss, Inc.

Thrombophilia and pregnancy complications: cause or association?

PubMed

Middeldorp, S

2007-07-01

Both acquired and inherited thrombophilia is associated with an increased risk of pregnancy failure (i.e. sporadic and recurrent miscarriage, late fetal loss), as well as hypertensive pregnancy complications such as pre-eclampsia and HELLP syndrome. The question of whether this relationship can be considered causal is rather philosophical. For practical purposes, the consistency and strengths of associations, potential mechanisms and, most importantly, the possibility to intervene with anticoagulants are reviewed. Relevant methodological issues in the case of thrombophilia and pregnancy complications consist of differences between observational and experimental research and quality issues in randomized controlled trials. The mechanisms associating thrombophilia and pregnancy complications are likely to involve effects on trophoblast differentiation rather than mere hypercoagulability. Therapeutic options comprise aspirin as well as (low molecular weight) heparin. For women with antiphospholipid antibody syndrome, this treatment is often suggested although the evidence is limited. For women with inherited thrombophilia and unexplained recurrent pregnancy loss, at present there is no evidence supporting treatment. Observational research is hampered by severe methodological flaws or inconsistent results. Two published randomized trials have not used an adequate comparator (i.e. no treatment or placebo). Currently, randomized controlled trials with no treatment or placebo are being carried out and results should be awaited before implementing a potentially harmful intervention in pregnant women with inherited thrombophilia and a history of pregnancy complications.

Prevalence and spectrum of large deletions or duplications in the major long QT syndrome-susceptibility genes and implications for long QT syndrome genetic testing.

PubMed

Tester, David J; Benton, Amber J; Train, Laura; Deal, Barbara; Baudhuin, Linnea M; Ackerman, Michael J

2010-10-15

Long QT syndrome (LQTS) is a cardiac channelopathy associated with syncope, seizures, and sudden death. Approximately 75% of LQTS is due to mutations in genes encoding for 3 cardiac ion channel α-subunits (LQT1 to LQT3). However, traditional mutational analyses have limited detection capabilities for atypical mutations such as large gene rearrangements. We set out to determine the prevalence and spectrum of large deletions/duplications in the major LQTS-susceptibility genes in unrelated patients who were mutation negative after point mutation analysis of LQT1- to LQT12-susceptibility genes. Forty-two unrelated, clinically strong LQTS patients were analyzed using multiplex ligation-dependent probe amplification, a quantitative fluorescent technique for detecting multiple exon deletions and duplications. The SALSA multiplex ligation-dependent probe amplification LQTS kit from MRC-Holland was used to analyze the 3 major LQTS-associated genes, KCNQ1, KCNH2, and SCN5A, and the 2 minor genes, KCNE1 and KCNE2. Overall, 2 gene rearrangements were found in 2 of 42 unrelated patients (4.8%, confidence interval 1.7 to 11). A deletion of KCNQ1 exon 3 was identified in a 10-year-old Caucasian boy with a corrected QT duration of 660 ms, a personal history of exercise-induced syncope, and a family history of syncope. A deletion of KCNQ1 exon 7 was identified in a 17-year-old Caucasian girl with a corrected QT duration of 480 ms, a personal history of exercise-induced syncope, and a family history of sudden cardiac death. In conclusion, because nearly 5% of patients with genetically elusive LQTS had large genomic rearrangements involving the canonical LQTS-susceptibility genes, reflex genetic testing to investigate genomic rearrangements may be of clinical value. Copyright © 2010 Elsevier Inc. All rights reserved.

Distinct neurohumoral biomarker profiles in children with hemodynamically defined orthostatic intolerance may predict treatment options

PubMed Central

Wagoner, Ashley L.; Shaltout, Hossam A.; Fortunato, John E.

2015-01-01

Studies of adults with orthostatic intolerance (OI) have revealed altered neurohumoral responses to orthostasis, which provide mechanistic insights into the dysregulation of blood pressure control. Similar studies in children with OI providing a thorough neurohumoral profile are lacking. The objective of the present study was to determine the cardiovascular and neurohumoral profile in adolescent subjects presenting with OI. Subjects at 10–18 yr of age were prospectively recruited if they exhibited two or more traditional OI symptoms and were referred for head-up tilt (HUT) testing. Circulating catecholamines, vasopressin, aldosterone, renin, and angiotensins were measured in the supine position and after 15 min of 70° tilt. Heart rate and blood pressure were continuously measured. Of the 48 patients, 30 patients had an abnormal tilt. Subjects with an abnormal tilt had lower systolic, diastolic, and mean arterial blood pressures during tilt, significantly higher levels of vasopressin during HUT, and relatively higher catecholamines and ANG II during HUT than subjects with a normal tilt. Distinct neurohumoral profiles were observed when OI subjects were placed into the following groups defined by the hemodynamic response: postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension (OH), syncope, and POTS/syncope. Key characteristics included higher HUT-induced norepinephrine in POTS subjects, higher vasopressin in OH and syncope subjects, and higher supine and HUT aldosterone in OH subjects. In conclusion, children with OI and an abnormal response to tilt exhibit distinct neurohumoral profiles associated with the type of the hemodynamic response during orthostatic challenge. Elevated arginine vasopressin levels in syncope and OH groups are likely an exaggerated response to decreased blood flow not compensated by higher norepinephrine levels, as observed in POTS subjects. These different compensatory mechanisms support the role of measuring neurohumoral profiles toward the goal of selecting more focused and mechanistic-based treatment options for pediatric patients with OI. PMID:26608337

Contemporary clinical trials in ventricular tachycardia and fibrillation: implications of ESVEM, CASCADE, and CASH for clinical management.

PubMed

Anderson, J L

1995-10-01

Recent clinical trials in patients with ventricular tachycardia (VT) or fibrillation (VF) have occurred in the setting of the disappointing results of postinfarction secondary prevention studies using Class I antiarrhythmics (e.g., CAST). ESVEM addressed in a randomized trial whether electrophysiologic study (EPS) or Holter monitoring (HM) is a more accurate predictor of long-term antiarrhythmic drug efficacy in VT/VF patients (N=486) and what the relative efficacy of various antiarrhythmic agents is for VT/VF. Surprisingly, arrhythmia recurrence rates were not significantly different by the method of determining an efficacy prediction. However, arrhythmia recurrence and mortality were lower (by about 50% at 1 year) in patients treated with sotalol (a mixed Class II/III agent) than with other drugs (Class I). CASCADE evaluated empiric amiodarone versus guided (EPS or HM) standard (Class I) therapy in survivors of out-of-hospital cardiac arrest due to VF. The primary endpoint of cardiac death, resuscitated VF, or syncopal shock (in ICD patients) was reduced by amiodarone compared with conventional therapy (9% vs 23% at 1 year). An interim report of the ongoing CASH study suggested in 230 survivors of cardiac arrest that propafenone (Class IC) provided less effective prophylaxis (approximately 20% 1-year mortality) compared with randomly assigned therapies with amiodarone, metoprolol, or an ICD (approximately 14% mortality rates) and was excluded from further study. These studies have led to a paradigm shift in the approach to antiarrhythmic therapy of VT/VF: drugs with antisympathetic plus Class III (refractoriness prolonging) action (i.e., sotalol, amiodarone) are superior to traditional drugs with Class I( conduction slowing) effects, even when guided by EPS or HM.

Fainting

MedlinePlus

... Syncope. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice ... by: Laura J. Martin, MD, MPH, ABIM Board Certified in Internal Medicine ...

Syncope

MedlinePlus

... Bridging Disciplines Circulation at Major Meetings Special Themed Issues Global Impact of the 2017 ACC/AHA Hypertension Guidelines Circulation Supplements Cardiovascular Case Series ECG Challenge Hospitals of History Brigham and ...

Balance Problems

MedlinePlus

... Other Resources Caregiving How To's Tools & Tips Latest Research Related Topics Arthritis Cataracts Fainting (Syncope) Falls Prevention Hearing Loss Macular Degeneration Physical Activity Related News Older Adults’ Use of Mobility ...

A Survey of Hospitalizations in Cardiology Units in Sub-Saharan Africa

ClinicalTrials.gov

2018-05-24

Acute Coronary Syndrome; Heart Failure; Syncope; Stroke; Pericarditis; Endocarditis; Conduction Abnormalities; Rhythm; Abnormal; Pulmonary Embolism; Deep Vein Thrombosis; Other Cardiovascular Conditions

Neurological Complications of Cardiac Disease.

PubMed

Madan, Nandini; Carvalho, Karen S

2017-02-01

This article focuses on the complex interactions between the cardiovascular and neurologic systems. Initially, we focus on neurological complications in children with congenital heart disease both secondary to the underlying cardiac disease and complications of interventions. We later discuss diagnosis and management of common syncope syndromes with emphasis on vasovagal syncope. We also review the diagnosis, classification, and management of children and adolescents with postural orthostatic tachycardia syndrome. Lastly, we discuss long QT syndrome and sudden unexpected death in epilepsy (SUDEP), reviewing advances in genetics and current knowledge of pathophysiology of these conditions. This article attempts to provide an overview of these disorders with focus on pathophysiology, advances in molecular genetics, and current medical interventions. Copyright © 2017 Elsevier Inc. All rights reserved.

Soft tissue involvement, mediastinal pseudotumor, and venous thrombosis in pustulotic arthro-osteitis. A study of eight new cases.

PubMed

van Holsbeeck, M; Martel, W; Dequeker, J; Favril, A; Gielen, J; Verschakelen, J; Hoogmartens, M

1989-01-01

A syndrome of hyperostosis of the thoracic wall, nonspecific signs of inflammatory disease, and palmar and plantar pustulosis is described in eight patients (Table 1). Seven had intersternocostoclavicular ossification, and one had chronic recurrent multifocal osteomyelitis. This complex of findings has been called "pustulotic arthro-osteitis". This report emphasizes the periosseous soft tissue inflammation and the unexplained subclavian and mediastinal vein thrombosis seen in two patients. Inflammatory periosseous and mediastinal lesions were seen on plain films in all eight patients and on computed tomographic (CT) scans in seven. Radiographs of the spine showed a spondyloarthropathy in three patients. This was characterized by ossification of the vertebral ligaments and sclerosis of the vertebral bodies. Awareness of the radiologic features of pustulotic arthro-osteitis is important because the clinical, biochemical and pathologic findings are often nonspecific and misleading.

Importance of Insulin Immunoassays in the Diagnosis of Factitious Hypoglycemia

PubMed Central

Nalbantoğlu Elmas, Özlem; Demir, Korcan; Soylu, Nusret; Çelik, Nilüfer; Özkan, Behzat

2014-01-01

We report two cases emphasizing the importance of insulin assays for evaluation of hypoglycemia in diabetic patients. Case 1 was a 96/12-year-old female patient with type 1 diabetes mellitus and case 2 was a 1010/12-year-old male patient with DIDMOAD. Both patients were on a basal-bolus insulin regimen. Both were admitted because of persistent hypoglycemia. Analyses of serum samples obtained at the time of hypoglycemia initially showed low insulin and C-peptide levels. Recurrent episodes of unexplained hypoglycemia necessitated measurement of insulin levels by using different insulin assays, which revealed hyperinsulinemic hypoglycemia with low C-peptide levels, findings which confirmed a diagnosis of factitious hypoglycemia. Surreptitious administration of insulin should not be excluded in diabetic patients with hypoglycemia without taking into account the rate of cross-reactivity of insulin analogues with the insulin assay used. PMID:25541899

Does autoimmunity play a role in the risk of implantation failures?

PubMed

Motak-Pochrzest, Hanna; Malinowski, Andrzej

2018-02-01

158 non-pregnant women with recurrent implantation failures after IVF/ET procedures were tested for peripheral blood autoimmune profile. The control group consisted of 76 patients after first successful IVF procedure and pregnancy outcome. The objective of this study was to investigate different autoantibodies peripheral blood profile after excluding anatomical, endocrinological, endometrial and genetic disorders and to estimate the risk of implantation failures. The study's including criteria were 1.indications for IVF/ET determined by male factor and unexplained infertility 2. absence of implantation after two consecutive cycles of IVF, ICSI or frozen embryo replacement cycles. The presence of ANA in the sera increased the risk of RIF after ET/IVF procedures, especially in older patients. Patients with RIF have a higher frequency of the presence of autoantibodies ACA IgG, IgM and anti-β2GP I IgG in the sera than in patients with successful pregnancies after IVF/ET procedures.

Intravenous immunoglobulin and idiopathic secondary recurrent miscarriage: a multicentered randomized placebo-controlled trial

PubMed Central

Stephenson, Mary D.; Kutteh, William H.; Purkiss, Susan; Librach, Cliff; Schultz, Patricia; Houlihan, Edwina; Liao, Chuanhong

2010-01-01

BACKGROUND Idiopathic secondary recurrent miscarriage may be associated with an abnormal maternal immune response to subsequent pregnancies. Intravenous immunoglobulin (IVIG) has been studied in randomized controlled trials (RCTs) with conflicting results. Therefore, a definitive trial was proposed. METHODS We conducted an investigator-initiated, multicentered, randomized, double-blinded, placebo-controlled trial comparing IVIG with saline in women with idiopathic secondary recurrent miscarriage, defined as a history of at least one prior ongoing pregnancy followed by three or more consecutive unexplained miscarriages. Subjects received either IVIG 500 mg/kg or the equivalent volume of normal saline. Preconception infusions were administered 14–21 days from the projected next menstrual period. With documentation of pregnancy, the subject received the same infusion every 4 weeks until 18–20 weeks of gestation. The primary outcome was an ongoing pregnancy of at least 20 weeks of gestation. RESULTS A total of 82 patients enrolled, of whom 47 had an index pregnancy. All ongoing pregnancies resulted in live births. Therefore, the live birth rates were 70% (16/23) in the IVIG group and 63% (15/24) in the control group (P = 0.760); odds ratio (OR) 1.37 [95% confidence interval (CI) 0.41–4.61]. Including only clinical pregnancies (embryo with cardiac activity at 6 weeks of gestation), the live birth rates were equivalent, 94% (16/17) and (15/16), respectively (P > 0.999); OR 1.07 (95% CI 0.06–18.62). Meta-analysis of randomized controlled trials (RCTs) evaluating IVIG for idiopathic secondary recurrent miscarriage revealed live birth rates of 70% (31/44) in the IVIG group and 62% (28/45) in the control group (P = 0.503); common OR 1.44 (95% CI 0.59–3.48). CONCLUSIONS This is the largest RCT to date in which IVIG was evaluated in women with idiopathic secondary recurrent miscarriage; no treatment benefit was found. The meta-analysis, which combined our study results with two prior RCTs, also showed no significant effect of treatment with IVIG. ClinicalTrials.gov NCT00606905. PMID:20634190

Evidence of Paternal N5, N10 - Methylenetetrahydrofolate Reductase (MTHFR) C677T Gene Polymorphism in Couples with Recurrent Spontaneous Abortions (RSAs) in Kolar District- A South West of India

PubMed Central

Vanilla, Shiny; Kotur, Pushpa F; Kutty, Moideen A; Vegi, Pradeep Kumar

2015-01-01

Introduction: Recurrent spontaneous abortion (RSA) is a multifactorial clinical obstetrics complication commonly occurring in pregnancy. Many research studies have noted the mutations such as C677T in N5, N10 - Methylenetetrahydrofolate reductase (MTHFR)gene which is regarded as RSA risk factor. This study was carried out to determine the occurrence of frequency of C677T of the MTHFR gene mutations with RSA. Aim: The purpose of present study is to determine the frequency of MTHFR C677T polymorphisms in couples with recurrent pregnancy loss and the impact of paternal polymorphisms of MTHFR C677T in recurrent pregnancy loss in population of couples living in Kolar district of Karnataka with RSA. Design: A total of 15 couples with a history of two or more unexplained RSA were enrolled as subjects in the study and a total of 15 couples with normal reproductive history, having two or more children and no history of miscarriages were enrolled as controls. Materials and Methods: DNA extraction from samples case and control group couples and its quantification by Agarose gel electrophoresis, assessment of DNA purity, MTHFR C 677T gene mutation detection by PCR-RFLP method. Statistical analysis: Carried out by web based online SPSS tool. Results: The frequency of C677T genotype showed homozygous wild type CC (80%), heterozygous CT type (13.3%) and homozygous mutation TT type (6.67%) observed in males. Similarly from female’s homozygous wild type CC (86.6%), heterozygous type (13.3%), and homozygous type mutations TT (0%) was recorded. In couple control groups, we observed homozygous wild type CC (86.6%), heterozygous CT type (13.3%) and homozygous type mutations TT type (0%). Conclusion: We noticed a high frequency of MTHFR specifically T allele associated with paternal side.Therefore, the present study indicated the impact of paternal gene polymorphism of MTHFR C677T on screening in couples with recurrent pregnancy loss. PMID:25859445

Usefulness of Medical Thoracoscopy in the Management of Pleural Effusion Caused by Chronic Renal Failure.

PubMed

Colella, Sara; Fioretti, Federica; Massaccesi, Chiara; Primomo, Gian L; Panella, Gianluca; D'Emilio, Vittorio; Pela, Riccardo

2017-10-01

Although pleural effusion (PE) can be caused by several pathologies like congestive heart failure, infections, malignancies, and pulmonary embolism, it is also a common finding in chronic kidney disease (CKD). Diagnostic thoracentesis is of limited value in the differential diagnosis, and the role of more invasive investigations like medical thoracoscopy (MT) is still unclear. To evaluate the usefulness of MT in unexplained PE in CKD. In the electronic database of our Institution, we retrospectively searched for patients with CKD who underwent MT for unexplained PE between January 2008 and August 2016. Ten patients were included in the present study. The average age was 72.4 years, the male:female ratio 9:1 and the average blood creatinine value 5.96 mg/dL. The average follow-up was 18 months.A thoracentesis showed an exudate was found in 9 patients and in 1 case pleural fluid characteristics were not recorded for technical reasons; in none of them the cytologic or microbiological analyses were considered diagnostic.The clinical suspicion was a neoplastic (5) or an infectious disease (5). In 4 patients with recurrent PE, MT was performed to obtain talc pleurodesis.No immediate procedure-related complications were recorded; 1 patient developed empyema after 2 months. In 6 cases final diagnosis was chronic uremic pleuritis, hydrothorax in 2, and chronic lymphocytic pleurisy in 2. MT represents a safe and effective diagnostic and therapeutic procedure in patients with CKD, that itself is a common cause of exudative effusion, and those patients may not require MT.

A Model of Compound Heterozygous, Loss-of-Function Alleles Is Broadly Consistent with Observations from Complex-Disease GWAS Datasets

PubMed Central

Sanjak, Jaleal S.; Long, Anthony D.; Thornton, Kevin R.

2017-01-01

The genetic component of complex disease risk in humans remains largely unexplained. A corollary is that the allelic spectrum of genetic variants contributing to complex disease risk is unknown. Theoretical models that relate population genetic processes to the maintenance of genetic variation for quantitative traits may suggest profitable avenues for future experimental design. Here we use forward simulation to model a genomic region evolving under a balance between recurrent deleterious mutation and Gaussian stabilizing selection. We consider multiple genetic and demographic models, and several different methods for identifying genomic regions harboring variants associated with complex disease risk. We demonstrate that the model of gene action, relating genotype to phenotype, has a qualitative effect on several relevant aspects of the population genetic architecture of a complex trait. In particular, the genetic model impacts genetic variance component partitioning across the allele frequency spectrum and the power of statistical tests. Models with partial recessivity closely match the minor allele frequency distribution of significant hits from empirical genome-wide association studies without requiring homozygous effect sizes to be small. We highlight a particular gene-based model of incomplete recessivity that is appealing from first principles. Under that model, deleterious mutations in a genomic region partially fail to complement one another. This model of gene-based recessivity predicts the empirically observed inconsistency between twin and SNP based estimated of dominance heritability. Furthermore, this model predicts considerable levels of unexplained variance associated with intralocus epistasis. Our results suggest a need for improved statistical tools for region based genetic association and heritability estimation. PMID:28103232

Correlation between protein expression of FOXP3 and level of FOXP3 promoter methylation in recurrent spontaneous abortion.

PubMed

Hou, Wenhui; Li, Zhuyu; Li, Yinguang; Fang, Liyuan; Li, Jie; Huang, Jia; Li, Xiaoqing; You, Zeshan

2016-11-01

The aim of this study was to investigate the level of Forkhead box P3 (FOXP3) promoter methylation and protein expression in recurrent spontaneous abortion and to elucidate the pathogenesis of unexplained recurrent spontaneous abortion (URSA). We assessed a total of 56 URSA patients with a normal embryo, 24 recurrent spontaneous abortion (RSA) patients with an abnormal embryo (as control group 1), and 39 normal pregnant women (as control group 2). The expression of FOXP3 protein in deciduas was assessed through Western blot, and the level of FOXP3 promoter methylation was detected using bisulfite-assisted genomic sequencing polymerase chain reaction. The expressing quantity of FOXP3 protein in the URSA group was significantly lower than that in control groups 1 and 2, both with a P-value < 0.05. By contrast, no statistical difference was observed in the expressing quantity of FOXP3 protein of the two control groups (P = 0.212). The FOXP3 promoter methylation level in the URSA group was significantly higher than that in the two control groups, both of which exhibited a statistical difference of P-values < 0.05. Meanwhile, no statistical difference was observed in the FOXP3 promoter methylation level of the two control groups (P = 0.141). A negative correlation was found between the FOXP3 promoter methylation level and the expressing quantity of FOXP3 protein (r = -0.861, P < 0.05). Increasing FOXP3 promoter methylation levels may cause abnormal immune tolerance through the downregulation expression of the FOXP3 protein, which in turn leads to URSA. © 2016 The Authors. Journal of Obstetrics and Gynaecology Research published by John Wiley & Sons Australia, Ltd on behalf of Japan Society of Obstetrics and Gynecology.

Clinical Usefulness of SPECT-CT in Patients with an Unexplained Pain in Metal on Metal (MOM) Total Hip Arthroplasty.

PubMed

Berber, Reshid; Henckel, Johann; Khoo, Michael; Wan, Simon; Hua, Jia; Skinner, John; Hart, Alister

2015-04-01

SPECT-CT is increasingly used to assess painful knee arthroplasties. The aim of this study was to evaluate the clinical usefulness of SPECT-CT in unexplained painful MOM hip arthroplasty. We compared the diagnosis and management plan for 19 prosthetic MOM hips in 15 subjects with unexplained pain before and after SPECT-CT. SPECT-CT changed the management decision in 13 (68%) subjects, Chi-Square=5.49, P=0.24. In 6 subjects (32%) pain remained unexplained however the result reassured the surgeon to continue with non-operative management. SPECT-CT should be reserved as a specialist test to help identify possible causes of pain where conventional investigations have failed. It can help reassure surgeons making management decisions for patients with unexplained pain following MOM hip arthroplasty. Copyright © 2014 Elsevier Inc. All rights reserved.

Inheritance of Febrile Seizures in Sudden Unexplained Death in Toddlers

PubMed Central

Holm, Ingrid A.; Poduri, Annapurna; Crandall, Laura; Haas, Elisabeth; Grafe, Marjorie R.; Kinney, Hannah C.; Krous, Henry F.

2014-01-01

Sudden unexplained death in toddlers has been associated with febrile seizures, family history of febrile seizures, and hippocampal anomalies. We investigated the mode of inheritance for febrile seizures in these families. A three-generation pedigree was obtained from families enrolled in the San Diego Sudden Unexplained Death in Childhood Research Project, involving toddlers with sudden unexplained death, febrile seizures, and family history of febrile seizures. In our six cases, death was unwitnessed and related to sleep. The interval from last witnessed febrile seizure to death ranged from 3 weeks to 6 months. Hippocampal abnormalities were identified in one of three cases with available autopsy sections. Autosomal dominant inheritance of febrile seizures was observed in three families. A fourth demonstrated autosomal dominant inheritance with incomplete penetrance or variable expressivity. In two families, the maternal and paternal sides manifested febrile seizures. In this series, the major pattern of inheritance in toddlers with sudden unexplained death and febrile seizures was autosomal dominant. Future studies should develop markers (including genetic) to identify which patients with febrile seizures are at risk for sudden unexplained death in childhood, and to provide guidance for families and physicians. PMID:22490769

Laparoscopy In Unexplained Abdominal Pain: Surgeon's Perspective.

PubMed

Abdullah, Muhammad Tariq; Waqar, Shahzad Hussain; Zahid, Muhammad Abdul

2016-01-01

Unexplained abdominal pain is a common but difficult presenting feature faced by the clinicians. Such patients can undergo a number of investigations with failure to reach any diagnosis. The objective of this study was to evaluate the use of laparoscopy in the diagnosis and management of patients with unexplained abdominal pain. This cross-sectional study was conducted at Pakistan Institute of Medical Sciences Islamabad from January 2009 to December 2013. This study included 91 patients of unexplained abdominal pain not diagnosed by routine clinical examination and investigations. These patients were subjected to diagnostic laparoscopy for evaluation of their conditions and to confirm the diagnosis. These patients presented 43% of patients undergoing investigations for abdominal pain. Patients diagnosed with gynaecological problems were excluded to see surgeon's perspective. The findings and the outcomes of the laparoscopy were recorded and data was analyzed. Unexplained abdominal pain is common in females than in males. The most common laparoscopic findings were abdominal tuberculosis followed by appendicitis. Ninety percent patients achieved pain relief after laparoscopic intervention. Laparoscopy is both beneficial and safe in majority of patients with unexplained abdominal pain. General surgeons should acquire training and experience in laparoscopic surgery to provide maximum benefit to these difficult patients.

Riociguat in patients with chronic thromboembolic pulmonary hypertension: results from an early access study.

PubMed

McLaughlin, Vallerie V; Jansa, Pavel; Nielsen-Kudsk, Jens E; Halank, Michael; Simonneau, Gérald; Grünig, Ekkehard; Ulrich, Silvia; Rosenkranz, Stephan; Gómez Sánchez, Miguel A; Pulido, Tomás; Pepke-Zaba, Joanna; Barberá, Joan Albert; Hoeper, Marius M; Vachiéry, Jean-Luc; Lang, Irene; Carvalho, Francine; Meier, Christian; Mueller, Katharina; Nikkho, Sylvia; D'Armini, Andrea M

2017-12-28

Following positive results from the Phase III CHEST-1 study in patients with inoperable or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH), the Phase IIIb CTEPH early access study (EAS) was designed to assess the safety and tolerability of riociguat in real-world clinical practice, as well as to provide patients with early access to riociguat before launch. Riociguat is approved for the treatment of inoperable and persistent/recurrent CTEPH. We performed an open-label, uncontrolled, single-arm, early access study in which 300 adult patients with inoperable or persistent/recurrent CTEPH received riociguat adjusted from 1 mg three times daily (tid) to a maximum of 2.5 mg tid. Patients switching from unsatisfactory prior pulmonary arterial hypertension (PAH)-targeted therapy (n = 84) underwent a washout period of at least 3 days before initiating riociguat. The primary aim was to assess the safety and tolerability of riociguat, with World Health Organization functional class and 6-min walking distance (6MWD) as exploratory efficacy endpoints. In total, 262 patients (87%) completed study treatment and entered the safety follow-up (median treatment duration 47 weeks). Adverse events were reported in 273 patients (91%). The most frequently reported serious adverse events were syncope (6%), right ventricular failure (3%), and pneumonia (2%). There were five deaths, none of which was considered related to study medication. The safety and tolerability of riociguat was similar in patients switched from other PAH-targeted therapies and those who were treatment naïve. In patients with data available, mean ± standard deviation 6MWD had increased by 33 ± 42 m at Week 12 with no clinically relevant differences between the switched and treatment-naïve subgroups. Riociguat was well tolerated in patients with CTEPH who were treatment naïve, and in those who were switched from other PAH-targeted therapies. No new safety signals were observed. ClinicalTrials.org NCT01784562 . Registered February 4, 2013.

Health care utilization of mexican patients with medically unexplained physical symptoms.

PubMed

Rodriguez González, Azucena Maribel; Ramírez Aranda, José Manuel; de Los Santos Reséndiz, Homero; Lara Duarte, María Yolanda; Pazaran Zanella, Santiago Oscar; Méndez López, Jafet Felipe; Gil Alfaro, Issa; Islas Ruz, Félix Gilberto; Navarrete Floriano, Gloria; Guillen Salomón, Edith; Texon Fernández, Obdulia; Cruz Duarte, Silvia; Romo Salazar, Juan Carlos; Pérez Ruiz, Claudia Elsa; López Salas, Sara de Jesús; Benítez Amaya, Lizbeth; Zapata Gallardo, Javier Nahum

2016-09-30

To determine the prevalence of medically unexplained physical symptoms and the characteristics and use of health services in a group of patients with medically unexplained physical symptoms and a group of patients with other illnesses. This was a cross-sectional, retrospective and multicenter study. We included 1,043 patients over 18 years of age from 30 primary care units of a government health institution, in 11 states of Mexico, attended by 39 family physicians. The prevalence of medically unexplained physical symptoms was determined and both groups with or without symptoms were compared with regard to drug use, laboratory and other studies, leaves of absence, and referrals in the last six months. The group with medically unexplained physical symptoms was diagnosed using the Patient Health Questionnaire and the diagnostic criteria of Reid et al . Emergency or terminal illnesses were excluded. The chi square test was used with a statistical significance of p < 0.05. Medically unexplained physical symptoms was diagnosed in 73 patients (7.0%). The majority were women (91.8%); their predominant symptom was from the gastrointestinal system in 56 (76.7%). This group had a greater use of clinical studies and referrals to other services (mean 1.1 vs. 0.5; p <0.0001 and 0.6 vs. 0.8; p < 0.01, respectively). The prevalence of medically unexplained physical symptoms was low, but with a greater impact on some health services. This could represent an overload in medical costs.

Syncope

MedlinePlus

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Race and fall risk: data from the National Health and Aging Trends Study (NHATS).

PubMed

Sun, Daniel Q; Huang, Jin; Varadhan, Ravi; Agrawal, Yuri

2016-01-01

the objective of this study was to explore whether race-based difference in fall risk may be mediated by environmental and physical performance risk factors. using data from a nationally representative longitudinal survey of 7,609 community-dwelling participants in the National Health and Aging Trends Study (NHATS), we evaluated whether racial differences in fall risk may be explained by physical performance level (measured by the Short Physical Performance Battery), mobility disability, physical activity level and likelihood of living alone. Multivariate Poisson regression and mediation models were used in analyses. in whites and blacks, the annual incidence of 'any fall' was 33.8 and 27.1%, respectively, and the annual incidence of 'recurrent falls' was 15.5 and 12.3%, respectively. Compared with whites, blacks had relative risks of 0.7 (95% confidence interval 0.6-0.8) and 0.6 (0.5-0.8) for sustaining any fall and recurrent falls, respectively, in adjusted analyses. Blacks had poorer performance on the SPPB (P < 0.001), higher levels of mobility disability (P < 0.001), similar levels of physical activity (P = 0.19) and were equally likely to live alone relative to whites (P = 0.77). Mediation analysis revealed that these risk factors collectively acted as suppressors and none of these factors accounted for the racial differences in fall risk observed. relative to whites, blacks were at 30 and 40% decreased risk of sustaining any fall and recurrent falls, respectively. This difference in risk remains unexplained. © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Recurrent Rearrangements of Chromosome 1q21.1 and Variable Pediatric Phenotypes

PubMed Central

Mefford, Heather C.; Sharp, Andrew J.; Baker, Carl; Itsara, Andy; Jiang, Zhaoshi; Buysse, Karen; Huang, Shuwen; Maloney, Viv K.; Crolla, John A.; Baralle, Diana; Collins, Amanda; Mercer, Catherine; Norga, Koen; de Ravel, Thomy; Devriendt, Koen; Bongers, Ernie M.H.F.; de Leeuw, Nicole; Reardon, William; Gimelli, Stefania; Bena, Frederique; Hennekam, Raoul C.; Male, Alison; Gaunt, Lorraine; Clayton-Smith, Jill; Simonic, Ingrid; Park, Soo Mi; Mehta, Sarju G.; Nik-Zainal, Serena; Woods, C. Geoffrey; Firth, Helen V.; Parkin, Georgina; Fichera, Marco; Reitano, Santina; Giudice, Mariangela Lo; Li, Kelly E.; Casuga, Iris; Broomer, Adam; Conrad, Bernard; Schwerzmann, Markus; Räber, Lorenz; Gallati, Sabina; Striano, Pasquale; Coppola, Antonietta; Tolmie, John L.; Tobias, Edward S.; Lilley, Chris; Armengol, Lluis; Spysschaert, Yves; Verloo, Patrick; De Coene, Anja; Goossens, Linde; Mortier, Geert; Speleman, Frank; van Binsbergen, Ellen; Nelen, Marcel R.; Hochstenbach, Ron; Poot, Martin; Gallagher, Louise; Gill, Michael; McClellan, Jon; King, Mary-Claire; Regan, Regina; Skinner, Cindy; Stevenson, Roger E.; Antonarakis, Stylianos E.; Chen, Caifu; Estivill, Xavier; Menten, Björn; Gimelli, Giorgio; Gribble, Susan; Schwartz, Stuart; Sutcliffe, James S.; Walsh, Tom; Knight, Samantha J.L.; Sebat, Jonathan; Romano, Corrado; Schwartz, Charles E.; Veltman, Joris A.; de Vries, Bert B.A.; Vermeesch, Joris R.; Barber, John C.K.; Willatt, Lionel; Tassabehji, May; Eichler, Evan E.

2009-01-01

BACKGROUND Duplications and deletions in the human genome can cause disease or predispose persons to disease. Advances in technologies to detect these changes allow for the routine identification of submicroscopic imbalances in large numbers of patients. METHODS We tested for the presence of microdeletions and microduplications at a specific region of chromosome 1q21.1 in two groups of patients with unexplained mental retardation, autism, or congenital anomalies and in unaffected persons. RESULTS We identified 25 persons with a recurrent 1.35-Mb deletion within 1q21.1 from screening 5218 patients. The microdeletions had arisen de novo in eight patients, were inherited from a mildly affected parent in three patients, were inherited from an apparently unaffected parent in six patients, and were of unknown inheritance in eight patients. The deletion was absent in a series of 4737 control persons (P = 1.1×10−7). We found considerable variability in the level of phenotypic expression of the microdeletion; phenotypes included mild-to-moderate mental retardation, microcephaly, cardiac abnormalities, and cataracts. The reciprocal duplication was enriched in the nine children with mental retardation or autism spectrum disorder and other variable features (P = 0.02). We identified three deletions and three duplications of the 1q21.1 region in an independent sample of 788 patients with mental retardation and congenital anomalies. CONCLUSIONS We have identified recurrent molecular lesions that elude syndromic classification and whose disease manifestations must be considered in a broader context of development as opposed to being assigned to a specific disease. Clinical diagnosis in patients with these lesions may be most readily achieved on the basis of genotype rather than phenotype. PMID:18784092

Cross-cultural differences in the epidemiology of unexplained fatigue syndromes in primary care.

PubMed

Skapinakis, Petros; Lewis, Glyn; Mavreas, Venetsanos

2003-03-01

Unexplained fatigue has been extensively studied but most of the samples used were from Western countries. To present international data on the prevalence of unexplained fatigue and fatigue as a presenting complaint in primary care. Method Secondary analysis of the World Health Organization study of psychological problems in general health care. A total of 5438 primary care attenders from 14 countries were assessed with the Composite International Diagnostic Interview. The prevalence of unexplained fatigue of 1-month duration differed across centres, with a range between 2.26 (95% CI 1.17-4.33) and 15.05 (95% CI 10.85-20.49). Subjects from more-developed countries were more likely to report unexplained fatigue but less likely to present with fatigue to physicians compared with subjects from less developed countries. In less-developed countries fatigue might be an indicator of unmet psychiatric need, but in more-developed countries it is probably a symbol of psychosocial distress.

Medically unexplained visual loss in a specialist clinic: a retrospective case-control comparison.

PubMed

O'Leary, Éanna D; McNeillis, Benjamin; Aybek, Selma; Riordan-Eva, Paul; David, Anthony S

2016-02-15

To compare the clinical and demographic characteristics of adult patients with nonorganic or medically unexplained visual loss (MUVL) to those with other common conditions presenting to a neuro-ophthalmology clinic. Case-control design: a retrospective review of medical notes on a consecutive case series of 49 patients assessed at the King's College Hospital neuro-ophthalmology clinic with unexplained visual loss and matched with the next assessed patient identified from clinic records. Patients presented post-symptom onset with a mean clinical course of 30 months (SD=67 months) and standard clinical examination used to confirm diagnoses, alongside ancillary investigations if required. Seventy-two percent (n=36) of MUVL patients were female. In comparison with patients with organic visual disorders, MUVL cases presented with significantly higher rates of bilateral (cf. unilateral) visual impairment (41%, n=20), premorbid psychiatric (27%, n=13) as well as functional (24%, n=12) diagnoses and psychotropic medication usage (22%, n=11). Medically unexplained cases were significantly more likely to report preceding psychological stress (n=9; 18%). Medically unexplained visual impairment may be regarded as part of the spectrum of medically unexplained disorders seen in the general hospital setting. Research is needed to determine long-term outcomes and effective tailored interventions. Copyright © 2016 Elsevier B.V. All rights reserved.

Diagnostic value of FDG-PET/(CT) in children with fever of unknown origin and unexplained fever during immune suppression.

PubMed

Blokhuis, Gijsbert J; Bleeker-Rovers, Chantal P; Diender, Marije G; Oyen, Wim J G; Draaisma, Jos M Th; de Geus-Oei, Lioe-Fee

2014-10-01

Fever of unknown origin (FUO) and unexplained fever during immune suppression in children are challenging medical problems. The aim of this study is to investigate the diagnostic value of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) and FDG-PET combined with computed tomography (FDG-PET/CT) in children with FUO and in children with unexplained fever during immune suppression. All FDG-PET/(CT) scans performed in the Radboud university medical center for the evaluation of FUO or unexplained fever during immune suppression in the last 10 years were reviewed. Results were compared with the final clinical diagnosis. FDG-PET/(CT) scans were performed in 31 children with FUO. A final diagnosis was established in 16 cases (52 %). Of the total number of scans, 32 % were clinically helpful. The sensitivity and specificity of FDG-PET/CT in these patients was 80 % and 78 %, respectively. FDG-PET/(CT) scans were performed in 12 children with unexplained fever during immune suppression. A final diagnosis was established in nine patients (75 %). Of the total number of these scans, 58 % were clinically helpful. The sensitivity and specificity of FDG-PET/CT in children with unexplained fever during immune suppression was 78 % and 67 %, respectively. FDG-PET/CT appears a valuable imaging technique in the evaluation of children with FUO and in the diagnostic process of children with unexplained fever during immune suppression. Prospective studies of FDG-PET/CT as part of a structured diagnostic protocol are warranted to assess the additional diagnostic value.

Common and unique associated factors for medically unexplained chronic widespread pain and chronic fatigue☆

PubMed Central

McBeth, J.; Tomenson, B.; Chew-Graham, C.A.; Macfarlane, G.J.; Jackson, J.; Littlewood, A.; Creed, F.H.

2015-01-01

Objective Chronic widespread pain and chronic fatigue share common associated factors but these associations may be explained by the presence of concurrent depression and anxiety. Methods We mailed questionnaires to a randomly selected sample of people in the UK to identify participants with chronic widespread pain (ACR 1990 definition) and those with chronic fatigue. The questionnaire assessed sociodemographic factors, health status, healthcare use, childhood factors, adult attachment, and psychological stress including anxiety and depression. To identify persons with unexplained chronic widespread pain or unexplained chronic fatigue; we examined participant's medical records to exclude medical illness that might cause these symptoms. Results Of 1443 participants (58.0% response rate) medical records of 990 were examined. 9.4% (N = 93) had unexplained chronic widespread pain and 12.6% (N = 125) had unexplained chronic fatigue. Marital status, childhood psychological abuse, recent threatening experiences and other somatic symptoms were commonly associated with both widespread pain and fatigue. No common effect was found for few years of education and current medical illnesses (more strongly associated with chronic widespread pain) or recent illness in a close relative, neuroticism, depression and anxiety scores (more strongly associated with chronic fatigue). Putative associated factors with a common effect were associated with unexplained chronic widespread pain or unexplained chronic fatigue only when there was concurrent anxiety and/or depression. Discussion This study suggests that the associated factors for chronic widespread pain and chronic fatigue need to be studied in conjunction with concurrent depression/anxiety. Clinicians should be aware of the importance of concurrent anxiety or depression. PMID:26652592

Making sense of medically unexplained symptoms in general practice: a grounded theory study

PubMed Central

2013-01-01

Background General practitioners often encounter patients with medically unexplained symptoms. These patients share many common features, but there is little agreement about the best diagnostic framework for describing them. Aims This study aimed to explore how GPs make sense of medically unexplained symptoms. Design Semi-structured interviews were conducted with 24 GPs. Each participant was asked to describe a patient with medically unexplained symptoms and discuss their assessment and management. Setting The study was conducted among GPs from teaching practices across Australia. Methods Participants were selected by purposive sampling and all interviews were transcribed. Iterative analysis was undertaken using constructivist grounded theory methodology. Results GPs used a variety of frameworks to understand and manage patients with medically unexplained symptoms. They used different frameworks to reason, to help patients make sense of their suffering, and to communicate with other health professionals. GPs tried to avoid using stigmatising labels such as ‘borderline personality disorder’, which were seen to apply a ‘layer of dismissal’ to patients. They worried about missing serious physical disease, but managed the risk by deliberately attending to physical cues during some consultations, and focusing on coping with medically unexplained symptoms in others. They also used referrals to exclude serious disease, but were wary of triggering a harmful cycle of uncoordinated care. Conclusion GPs were aware of the ethical relevance of psychiatric diagnoses, and attempted to protect their patients from stigma. They crafted helpful explanatory narratives for patients that shaped their experience of suffering. Disease surveillance remained an important role for GPs who were managing medically unexplained symptoms. PMID:24427176

Sperm chromatin structure assay results in Nigerian men with unexplained infertility

PubMed Central

Kolade, Charles Oluwabukunmi

2015-01-01

Objective Several publications have established a relationship between sperm DNA damage and male factor infertility, based on data from America, Europe, and Asia. This study aimed to compare the extent of sperm DNA damage in sperm samples from Nigerian men with unexplained infertility and in sperm samples from a fertile group composed of sperm donors who had successfully impregnated a female partner naturally or through assisted conception. Methods A total of 404 men underwent male fertility evaluation at Androcare Laboratories and Cryobank participated in this study. Semen analysis and a sperm chromatin structure assay (SCSA) were performed on all subjects. Results The men in the unexplained infertility group were slightly older than the men in the fertile sperm group (36±10 years vs. 32±6 years, p=0.051). No significant difference was observed between the two groups in semen analysis parameters (p≥0.05). Men in the unexplained infertility group with normal semen parameters had a significantly higher DNA fragmentation index (DFI) than men in the fertile sperm group (27.5%±7.0% vs. 14.1%±5.3%, p<0.05). In the unexplained infertility group, 63% of the men had a DFI greater than 20%, compared to 4% in the fertile sperm group. In the unexplained infertility group, 15.2% of the subjects had a DFI greater than 30%, compared to 1% in the fertile sperm group. Conclusion Our study showed that the SCSA may be a more reliable predictor of fertility potential than traditional semen analysis in cases of unexplained infertility. PMID:26473109

49 CFR 391.43 - Medical examination; certificate of physical examination.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., congestive heart failure, or cardiovascular disease that is accompanied by syncope, dyspnea, or collapse... ear disease, symptoms of aural vertigo, or Meniere's Syndrome. When recording hearing, record distance...

Fainting during Urination (Micturition Syncope): What Causes It?

MedlinePlus

... of Privacy Practices Notice of Nondiscrimination Manage Cookies Advertising Mayo Clinic is a not-for-profit organization and proceeds from Web advertising help support our mission. Mayo Clinic does not ...

Mechanisms of lower body negative pressure-induced syncope

NASA Astrophysics Data System (ADS)

Davrath, Linda Ruble

Although extensively investigated, the mechanisms of post-spaceflight orthostatic intolerance have not been elucidated. The working hypothesis was that a markedly reduced left ventricular end-systolic volume (LVESV) would be achieved during progressive, presyncopal-limited LBNP and would cause bradycardia and a fall in blood pressure, thus triggering syncope. Eight healthy men, age 25.1 ± 1.3 years, volunteered for the study. Subjects were exposed to graded levels of LBNP on two separate occasions. Changes in left ventricular end-diastolic volume and LVESV were measured, using two-dimensional echocardiography, at each stage of LBNP from rest to presyncope. Plasma venous blood samples were withdrawn at the end of each stage of the LBNP protocol for the measurement of plasma venous catecholamines and plasma renin activity (PRA). Catecholamines were analyzed by HPLC with electro-chemical detection, and PRA was determined by radioimmunoassay. All subjects reached presyncope during the LBNP. LVESV decreased by 28% at presyncope with no evidence of ventricular cavity obliteration. Norepinephrine (NE) increased by 44% from rest to presyncope, but no epinephrine surge was detected (35% increase from rest to presyncope). These data indicate that it is possible to initiate syncope with only a 28% decrease in LVESV, and that sympatho-inhibition and bradycardia are not required elements for syncope to occur. To investigate the effect of moderate sodium restriction on cardiovascular hemodynamics and orthostatic tolerance, presyncopal LBNP testing was performed. Urinary sodium excretion was significantly higher on the normal-sodium diet when compared with the sodium-restricted diet, but urinary potassium was not different. Cumulative stress index (655 ± 460 on normal-sodium diet vs. 639 ± 388 on sodium-restricted diet) scores were not different. Cardiac volumes, blood pressure and total peripheral resistance were not different at any stage of the LBNP between the diets, nor were plasma catecholamine levels. Heart rate was significantly higher at presyncope on the sodium-restricted diet. Plasma renin activity was significantly higher during sodium restriction at rest, and during all stages of LBNP. Moderate dietary sodium restriction was not accompanied by apparent plasma volume reduction (hematocrit, body weight change), and did not appear to be detrimental to orthostatic function.

Outreach syncope clinic managed by a nurse practitioner: Outcome and cost effectiveness.

PubMed

Hamdan, Mohamed H; Walsh, Kathleen E; Brignole, Michele; Key, Jamie

2017-01-01

Introduction The purpose of this study was to assess the clinical and financial outcomes of a novel outreach syncope clinic. Methods We compared the clinical outcome of the Faint and Fall Clinic at the American Center (January-June 2016) with that of the University of Wisconsin Health and Clinics Faint and Fall Clinic (January 2013-December 2014). The American Center-Faint and Fall Clinic is run solely by a nurse practitioner, assisted by online faint-decision software and consultancy of a faint specialist through video-conferencing. Results Five hundred and twenty-eight consecutive patients were seen at the University of Wisconsin Hospital and Clinics-Faint and Fall Clinic and 68 patients at the American Center-Faint and Fall Clinic. The patients' clinical characteristics were similar except for a lower age in the American Center patients (45 ± 18 vs 51 ± 22, p = 0.03). Overall, a diagnosis was made within 45 days in 70% (95% confidence interval 66-74%) of the University of Wisconsin Hospital and Clinics patients and 69% (95% confidence interval 58-80%) of the American Center patients, ( p = 0.9). A mean of 3.0 ± 1.6 tests per patient was used in the University of Wisconsin Hospital and Clinics group compared to 1.5 ± 0.8 tests per patient in the American Center group, p = 0.001. Over the six-month study period, the total revenue at the American Center was US$152,597 (contribution margin of US$122,393 plus professional revenue of US$30,204). The total cost of the nurse practitioner including benefits was US$66,662 ((US$98,466 salary/year + 35.4% benefits)/2). Total revenue minus expenses resulted in a net profit of US$85,935. Discussion A nurse practitioner-run outreach syncope-clinic equipped with online faint-decision software and consultancy of a faint specialist through vedio-conferencing is feasible and financially self-sustainable. It allows the dissemination of standardized high-quality syncope care to patients who have no immediate access to a tertiary teaching hospital.

Recurrent Renal Colic in a Patient with Munchausen Syndrome

PubMed Central

Miconi, Francesco; Rapaccini, Valentina; Savarese, Emanuela; Cabiati, Gabriele; Pasini, Augusto; Miconi, Giovanni; Principi, Nicola

2018-01-01

Background: In most of the cases regarding children, factitious disorders (FDs) are intentionally produced by parents. Less attention is paid to FDs in which a child or adolescent intentionally induces or falsifies the disease to attain a patient’s role. Case presentation: A 13-year-old immigrated and adopted boy previously underwent an operation for renal joint syndrome and was affected by recurrent episodes of renal colic. The boy was admitted reporting acute left flank pain with scars on the mucous face of his prepuce and had a recent previous hospitalization for the same reason. Laboratory tests and radiological findings did not reveal any morphological or functional alterations. Self-induced FD was suspected, and a psychiatric consultation was performed. After psychiatric consultation and remission of the symptoms with a placebo, a diagnosis of Munchausen syndrome was suspected. The patient’s uncle was not initially convinced of the diagnosis. Some videos clearly showed that the boy was handling his prepuce to excrete stones, explaining the scars. A therapeutic plan with psychiatrist support was later accepted with a positive outcome. No further signs and symptoms of renal colic were reported. Conclusions: It is recommended that paediatricians include FD in the differential diagnosis of a persistent and unexplained medical condition. If suspicion arises, confirmation and long-term therapy by a group of qualified specialists, including psychiatrists, should be planned. PMID:29596350

1alpha,25-dihydroxy-vitamin-D3 as new immunotherapy in treatment of recurrent spontaneous abortion.

PubMed

Bubanovic, I

2004-01-01

Recurrent spontaneous abortion (RSA) is serious health problem affecting 2-5% of reproducing couples worldwide. It has long been suspected that nearly 80% of the unexplained RSAs are due to immunologic causes. Although the major tissue confronting the mother's immune system is the placental villous trophoblast, the immunological risk to the developing embryo is not great until the time of implantation. In addition, trophoblast is not sensible to lysis by NK cells, TNF-alpha or macrophages, but may be killed by lymphokine activated NK cells (LAK) and may undergo apoptosis in response to TNF-alpha and/or IFN-gamma in vitro. The two most commonly used treatments for RSA are intravenous immunoglobulin (IVIg) and alloimmunization with partner's leukocytes (LIT). We promote vitamin D3 as new immunomodulatory agent in treatment of RSA. Different mechanisms have been proposed to account for the immunosuppressive effect of 1alpha, 25-dihydroxy-vitamin-D3 (VD3). Portion of the VD3 activity involves the downregulation of IL-2, IFN-gamma and TNF-alpha genes transcription. Because immunomodulatory effects of VD3 are very similar to IL-10 effects, acting of VD3 in immunotherapy of RSA syndrome, preeclamptic and eclamptic pregnancy, as well as PIH syndrome, is very reasonable. We propose using of VD3 as immunotherapy or adjuvant therapy in combination with classic immunotherapies of endangered pregnancies.

Effects of polyvalent immunoglobulins in patients with recurrent pregnancy loss and antibodies to the choriocarcinoma cell line JEG-3.

PubMed

Rogenhofer, Nina; von Schönfeldt, Viktoria; Ochsenkühn, Robert; Sili, Felicia; Thaler, Christian J

2015-11-01

The benefit of polyvalent immunoglobulins (IVIG) for patients with recurrent pregnancy loss (RPL) is controversially discussed. Anti-trophoblast antibodies as an expression of immune pathology have been associated with RPL. We investigated whether the antibody activity against the choriocarcinoma cell line JEG-3 in RPL patients is influenced in vitro by IVIG. Sera of 110 unexplained RPL patients with positive anti-JEG-3 antibodies were coincubated with IVIG in different concentrations (10mg/ml, 20mg/ml, 40mg/ml). Coincubation with human albumin in identical concentrations served as control. Anti-JEG-3 reactivity was measured by using flow cytometry in comparisons with two in-house standards antibody probes of low and high reactivity as described before. Anti-JEG-3 reactivity above the 95% confidence interval of controls was defined as positive. Incubating RPL sera with 10mg/ml IVIG significantly decreased anti-JEG-3 activity (p<0.001). Increasing IVIG concentration to 40mg/ml resulted in a slightly additionally reduction (p=0.42). In contrast, coincubation with albumin in identically concentrations did not affect anti-JEG-3 activity (p>0.40). Coincubation with IVIG in vitro leads to a significant suppression of anti-JEG-3 activity in the sera of RPL patients. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Pacemaker lead perforation of the right ventricle associated with Moraxella phenylpyruvica infection in a dog.

PubMed

Ciavarella, A; Nimmo, J; Hambrook, L

2016-04-01

A 13-year-old neutered male Border Collie was presented with acute onset syncope, weakness and anorexia 10 months after transvenous pacemaker implantation. The patient was laterally recumbent, bradycardic (36 beats/min) and febrile (40.7°C) on presentation. An electrocardiogram (ECG) revealed recurrence of third-degree atrioventricular block with a ventricular escape rhythm. Fluoroscopy identified migration of the pacemaker tip through the apex of the right ventricle. Echocardiography failed to reveal any evidence of pericardial effusion or cardiac tamponade. Full postmortem was performed after euthanasia. The pacemaker lead had perforated the apex of the right ventricle and lodged in the right pleural space. Culture of blood (taken antemortem), pericardial sac, right ventricular wall (surrounding pacemaker lead), pacemaker lead tip and pericardial fluid revealed a pure growth of Moraxella phenylpyruvica. Bacteraemia associated with M. phenylpyruvica has never been reported in the dog, but sporadic cases are reported in humans. Infection could have resulted from either pre-existing myocarditis or opportunistic infection and bacteraemia post pacemaker implantation. Evaluation of the pacemaker function at regular intervals would allow early detection of poor pacemaker-to-myocardium contact, which would prompt further investigation of pacemaker lead abnormalities such as perforation. © 2016 Australian Veterinary Association.

Structured syncope care pathways based on lean six sigma methodology optimises resource use with shorter time to diagnosis and increased diagnostic yield.

PubMed

Martens, Leon; Goode, Grahame; Wold, Johan F H; Beck, Lionel; Martin, Georgina; Perings, Christian; Stolt, Pelle; Baggerman, Lucas

2014-01-01

To conduct a pilot study on the potential to optimise care pathways in syncope/Transient Loss of Consciousness management by using Lean Six Sigma methodology while maintaining compliance with ESC and/or NICE guidelines. Five hospitals in four European countries took part. The Lean Six Sigma methodology consisted of 3 phases: 1) Assessment phase, in which baseline performance was mapped in each centre, processes were evaluated and a new operational model was developed with an improvement plan that included best practices and change management; 2) Improvement phase, in which optimisation pathways and standardised best practice tools and forms were developed and implemented. Staff were trained on new processes and change-management support provided; 3) Sustaining phase, which included support, refinement of tools and metrics. The impact of the implementation of new pathways was evaluated on number of tests performed, diagnostic yield, time to diagnosis and compliance with guidelines. One hospital with focus on geriatric populations was analysed separately from the other four. With the new pathways, there was a 59% reduction in the average time to diagnosis (p = 0.048) and a 75% increase in diagnostic yield (p = 0.007). There was a marked reduction in repetitions of diagnostic tests and improved prioritisation of indicated tests. Applying a structured Lean Six Sigma based methodology to pathways for syncope management has the potential to improve time to diagnosis and diagnostic yield.

Structured Syncope Care Pathways Based on Lean Six Sigma Methodology Optimises Resource Use with Shorter Time to Diagnosis and Increased Diagnostic Yield

PubMed Central

Martens, Leon; Goode, Grahame; Wold, Johan F. H.; Beck, Lionel; Martin, Georgina; Perings, Christian; Stolt, Pelle; Baggerman, Lucas

2014-01-01

Aims To conduct a pilot study on the potential to optimise care pathways in syncope/Transient Loss of Consciousness management by using Lean Six Sigma methodology while maintaining compliance with ESC and/or NICE guidelines. Methods Five hospitals in four European countries took part. The Lean Six Sigma methodology consisted of 3 phases: 1) Assessment phase, in which baseline performance was mapped in each centre, processes were evaluated and a new operational model was developed with an improvement plan that included best practices and change management; 2) Improvement phase, in which optimisation pathways and standardised best practice tools and forms were developed and implemented. Staff were trained on new processes and change-management support provided; 3) Sustaining phase, which included support, refinement of tools and metrics. The impact of the implementation of new pathways was evaluated on number of tests performed, diagnostic yield, time to diagnosis and compliance with guidelines. One hospital with focus on geriatric populations was analysed separately from the other four. Results With the new pathways, there was a 59% reduction in the average time to diagnosis (p = 0.048) and a 75% increase in diagnostic yield (p = 0.007). There was a marked reduction in repetitions of diagnostic tests and improved prioritisation of indicated tests. Conclusions Applying a structured Lean Six Sigma based methodology to pathways for syncope management has the potential to improve time to diagnosis and diagnostic yield. PMID:24927475

Influence of tilt training on activation of the autonomic nervous system in patients with vasovagal syncope.

PubMed

Gajek, Jacek; Zyśko, Dorota; Halawa, Bogumił; Mazurek, Walentyna

2006-04-01

Tilt training is a new treatment for vasovagal syncope. Its therapeutic efficacy is thought to be the result of the desensitization of cardiopulmonary receptors, but it could be the influence of the tilt training on the activation of the autonomic nervous system as well. The study group consisted of 24 vasovagal patients (17 women and 7 men) aged 32.5 +/- 11.8 years. The diagnostic head-up tilt test was performed according to the Italian protocol with nitroglycerin if necessary. The monitoring head-up tilt test was performed according to the Westminster protocol without provocation, after 1 to 3 months of tilt training. Holter ECG recordings for HRV parameters (time and frequency domain) were obtained from selected 2-min intervals before, during and after the diagnostic and monitoring tilt test. The diagnostic test was positive in the passive phase in 6 and after provocation in 18 patients. During the training period no syncope occurred. Analysing the HRV parameters we demonstrated the following findings: I. mRR decreases immediately after assumption of a vertical position in both tests (diagnostic and monitoring) but in the diagnostic test its further decrease occurs earlier than in the monitoring test; 2. the absolute power of the HF component is greater in the early phase of tilt after tilt training than in the corresponding period in the diagnostic test. After a longer period of tilt training the activation of the sympathetic nervous system in response to the erect position is diminished.

How do hospital doctors manage patients with medically unexplained symptoms: a qualitative study of physicians.

PubMed

Warner, Alex; Walters, Kate; Lamahewa, Kethakie; Buszewicz, Marta

2017-02-01

Objective Medically unexplained symptoms are a common presentation in medical practice and are associated with significant morbidity and high levels of service use. Most research exploring the attitudes and training of doctors in treating patients with unexplained symptoms has been conducted in primary care. This study aims to explore the ways in which doctors working in secondary care approach and manage patients with medically unexplained symptoms. Design A qualitative study using in-depth interviews and thematic analysis. Setting Three hospitals in the North Thames area. Participants Twenty consultant and training-grade physicians working in cardiology, gastroenterology, rheumatology and neurology. Main outcome measure Physicians' approach to patients with medically unexplained symptoms and their views on managing these patients. Results There was considerable variation in how the physicians approached patients who presented with medically unexplained symptoms. Investigations were often ordered without a clear rationale and the explanations given to patients when results of investigations were normal were highly variable, both within and across specialties. The doctor's level of experience appeared to be a more important factor in their investigation and management strategies than their medical specialty. Physicians reported little or no formal training in how to manage such presentations, with no apparent consistency in how they had developed their approach. Doctors described learning from their own experience and from senior role models. Organisational barriers were identified to the effective management of these patients, particularly in terms of continuity of care. Conclusions Given the importance of this topic, there is a need for serious consideration as to how the management of patients with medically unexplained symptoms is included in medical training and in the planning and delivery of services.

Lower FOXO3 mRNA expression in granulosa cells is involved in unexplained infertility.

PubMed

Yamamoto, Hikaru; Yamashita, Yoshiki; Saito, Natsuho; Hayashi, Atsushi; Hayashi, Masami; Terai, Yoshito; Ohmichi, Masahide

2017-06-01

The aim of this study was to investigate whether FOXO1 and FOXO3 mRNA expression in granulosa cells is the cause of unexplained infertility. Thirty-one patients aged <40 years (13 with unexplained infertility and 18 with male partner infertility as a control group) whose serum anti-Müllerian hormone level was >0.5 ng/μL were enrolled in the study. All patients underwent oocyte retrieval under a short protocol from June 2012 to October 2013. Real-time PCR was carried out using mRNA extracted from granulosa cells retrieved from mature follicles. We compared FOXO1 and FOXO3 mRNA expression ratios in granulosa cells between the unexplained infertility group and the male infertility group. The relation between FOXO1 and FOXO3 mRNA expression ratios in granulosa cells and assisted reproduction technology clinical outcome was also examined. FOXO3 mRNA expression ratio was significantly lower in the unexplained infertility group than in the male infertility group. Moreover, FOXO3 mRNA expression ratio showed a positive correlation with both the number of retrieved oocytes and serum anti-Müllerian hormone level. A positive correlation was also identified between FOXO1 mRNA expression and total dose of hMG. As well, the number of retrieved oocytes in the unexplained infertility group was statistically lower than that in the male infertility group. A lower FOXO3 mRNA expression in granulosa cells leads to poor oocyte development in patients with unexplained infertility undergoing controlled ovarian stimulation for in vitro fertilization-embryo transfer. © 2017 Japan Society of Obstetrics and Gynecology.

Multi-symptom illnesses, unexplained illness and Gulf War Syndrome

PubMed Central

Ismail, Khalida; Lewis, Glyn

2006-01-01

Explanatory models for the increased prevalence of ill health in Gulf veterans compared to those not deployed to the Gulf War 1990–1991 remain elusive. This article addresses whether multi-symptom reporting in Gulf veterans are types of medically unexplained symptoms and whether the alleged Gulf War Syndrome is best understood as a medically unexplained syndrome. A review of the epidemiological studies, overwhelmingly cross-sectional, describing ill health was conducted including those that used factor analysis to search for underlying or latent clinical constructs. The overwhelming evidence was that symptoms in Gulf veterans were either in keeping with currently defined psychiatric disorders such as depression and anxiety or were medically unexplained. The application of factor analysis methods had varied widely with a risk of over interpretation in some studies and limiting the validity of their findings. We concluded that ill health in Gulf veterans and the alleged Gulf War Syndrome is best understood within the medically unexplained symptoms and syndromes constructs. The cause of increased reporting in Gulf veterans are still not clear and requires further inquiry into the interaction between sociological factors and symptomatic distress. PMID:16687260

Definition and epidemiology of unexplained infertility.

PubMed

Gelbaya, Tarek A; Potdar, Neelam; Jeve, Yadava B; Nardo, Luciano G

2014-02-01

The diagnosis of unexplained infertility can be made only after excluding common causes of infertility using standard fertility investigations,which include semen analysis, assessment of ovulation, and tubal patency test. These tests have been selected as they have definitive correlation with pregnancy. It is estimated that a standard fertility evaluation will fail to identify an abnormality in approximately 15% to 30% of infertile couples. The reported incidence of such unexplained infertility varies according to the age and selection criteria in the study population. We conducted a review of the literature via MEDLINE. Articles were limited to English-language, human studies published between 1950 and 2013. Since first coined more than 50 years ago, the term unexplained infertility has been a subject of debate. Although additional investigations are reported to explain or define other causes of infertility, these have high false-positive results and therefore cannot be recommended for routine clinical practice. Couples with unexplained infertility might be reassured that even after 12 months of unsuccessful attempts, 50% will conceive in the following 12 months and another 12% in the year after.

Retrospective Validation of a Surveillance System for Unexplained Illness and Death: New Haven County, Connecticut

PubMed Central

Kluger, Michael D.; Sofair, Andre N.; Heye, Constance J.; Meek, James I.; Sodhi, Rajesh K.; Hadler, James L.

2001-01-01

Objectives. This study investigated retrospective validation of a prospective surveillance system for unexplained illness and death due to possibly infectious causes. Methods. A computerized search of hospital discharge data identified patients with potential unexplained illness and death due to possibly infectious causes. Medical records for such patients were reviewed for satisfaction of study criteria. Cases identified retrospectively were combined with prospectively identified cases to form a reference population against which sensitivity could be measured. Results. Retrospective validation was 41% sensitive, whereas prospective surveillance was 73% sensitive. The annual incidence of unexplained illness and death due to possibly infectious causes during 1995 and 1996 in the study county was conservatively estimated to range from 2.7 to 6.2 per 100 000 residents aged 1 to 49 years. Conclusions. Active prospective surveillance for unexplained illness and death due to possibly infectious causes is more sensitive than retrospective surveillance conducted through a published list of indicator codes. However, retrospective surveillance can be a feasible and much less labor-intensive alternative to active prospective surveillance when the latter is not possible or desired. PMID:11499106

Endometrial injury to overcome recurrent embryo implantation failure: a systematic review and meta-analysis.

PubMed

Potdar, Neelam; Gelbaya, Tarek; Nardo, Luciano G

2012-12-01

Mechanical endometrial injury (biopsy/scratch or hysteroscopy) in the cycle preceding ovarian stimulation for IVF has been proposed to improve implantation in women with unexplained recurrent implantation failure (RIF). This is a systematic review and meta-analysis of studies comparing the efficacy of endometrial injury versus no intervention in women with RIF undergoing IVF. All controlled studies of endometrial biopsy/scratch or hysteroscopy performed in the cycle preceding ovarian stimulation were included and the primary outcome measure was clinical pregnancy rate. Pooling of seven controlled studies (four randomized and three non-randomized), with 2062 participants, showed that local endometrial injury induced in the cycle preceding ovarian stimulation is 70% more likely to result in a clinical pregnancy as opposed to no intervention. There was no statistically significant heterogeneity in the methods used, clinical pregnancy rates being twice as high with biopsy/scratch (RR 2.32, 95% CI 1.72-3.13) as opposed to hysteroscopy (RR 1.51, 95% CI 1.30-1.75). The evidence is strongly in favour of inducing local endometrial injury in the preceding cycle of ovarian stimulation to improve pregnancy outcomes in women with unexplained RIF. However, large randomized studies are required before iatrogenic induction of local endometrial injury can be warranted in routine clinical practice. Some women undergoing IVF treatment fail to conceive despite several attempts with good-quality embryos and no identifiable reason. We call this 'recurrent implantation failure' (RIF) where the embryo fails to embed or implant within the lining of the womb. Studies have shown that inducing injury to the lining of the womb in the cycle before starting ovarian stimulation for IVF can help improve the chances of achieving pregnancy. Injury can be induced by either scratching the lining of the womb using a biopsy tube or by telescopic investigation of the womb using a camera. We performed a collective review of the available good-quality studies that used the above two methods in the cycle prior to starting ovarian stimulation for IVF. We pooled results from seven studies, which included 2062 women with RIF and assessed the difference in clinical pregnancy rates for those undergoing injury to the womb lining compared with no injury prior to IVF. The results suggest that inducing injury is 70% more likely to result in a clinical pregnancy as opposed to no treatment. Furthermore, scratching of the lining was 2-times more likely to result in a clinical pregnancy compared with telescopic evaluation of the lining of the womb. This study suggests that in women with RIF, inducing local injury to the womb lining in the cycle prior to starting ovarian stimulation for IVF can improve pregnancy outcomes. However, large studies are required before this can be warranted in routine clinical practice. Copyright © 2012 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Effectiveness of a Blended Multidisciplinary Intervention for Patients with Moderate Medically Unexplained Physical Symptoms (PARASOL): Protocol for a Cluster Randomized Clinical Trial.

PubMed

van Westrienen, Paula Elisabeth; Pisters, Martijn F; Toonders, Suze Aj; Gerrits, Marloes; Veenhof, Cindy; de Wit, Niek J

2018-05-08

Medically unexplained physical symptoms are an important health problem in primary care, with a spectrum from mild to chronic. The burden of chronic medically unexplained physical symptoms is substantial for patients, health care professionals, and society. Therefore, early identification of patients with moderate medically unexplained physical symptoms is needed in order to prevent chronicity. The preventive screening of medically unexplained physical symptoms (PRESUME) screening method was developed using data from the electronic medical record of the patients' general practitioner and demonstrated its prognostic accuracy to identify patients with moderate medically unexplained physical symptoms. In the next step, we developed a proactive blended and integrated mental health and physical therapy intervention program (PARASOL) to reduce complaints of moderate medically unexplained physical symptoms, stimulate self-management, and prevent chronicity. The primary objective of this study is to investigate the effectiveness of the blended PARASOL intervention on the impact of symptoms and quality of life in patients with moderate medically unexplained physical symptoms compared with usual care. Secondary objectives are to study the effect on severity of physical and psychosocial symptoms, general health, physical behavior, illness perception, and self-efficacy in patients with moderate medically unexplained physical symptoms as well as to determine the cost-effectiveness of the program. This paper presents the study protocol of a multicenter cluster randomized clinical trial. Adult patients with moderate medically unexplained physical symptoms will be identified from electronic medical record data using the PRESUME screening method and proactively recruited for participation in the study. Cluster randomization will be performed at the level of the participating health care centers. In total 248 patients with moderate medically unexplained physical symptoms (124 patients per arm) are needed. The PARASOL intervention is a 12-week blended primary care program consisting of 4 face-to-face consultations with the mental health nurse and 5 physical therapy sessions, supplemented with a Web-based program. The Web-based program contains (1) information modules and videos on self-management and educative themes, (2) videos and instructions on prescribed home exercises, and (3) assignments to gradually increase the physical activity. The program is directed at patients' perception of symptoms as well as modifiable prognostic risk factors for chronicity using therapeutic neuroscience education. It encourages self-management, as well as an active lifestyle using a cognitive behavioral approach and graded activity. Primary outcomes are impact of symptoms and quality of life. Secondary outcomes are severity of physical and psychosocial symptoms, general health, physical behavior, illness perceptions, self-efficacy, and cost-effectiveness. All measurements will be performed at baseline, 3 and 12 months after baseline. Retrospective cost questionnaires will also be sent at 6 and 9 months after baseline and these will be used for the cost-effectiveness analysis. The intervention has been developed, and the physical therapists and mental health nurses in the participating experimental health care centers have received two days of training on the content of the blended PARASOL intervention. The recruitment of health care centers started in June 2016 and inclusion of patients began in March 2017. Follow-up assessments of patients are expected to be completed in March 2019. This study is the first randomized clinical trial to determine the effectiveness (including cost-effectiveness) of a proactive, blended, and integrated mental health and physical therapy care program for patients with moderate medically unexplained physical symptoms. The findings will help to improve the treatment for patients with moderate medically unexplained physical symptoms and prevent chronicity. Netherlands Trial Register NTR6755; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6755 (Archived by WebCite at http://www.webcitation.org/6ywporY7u). ©Paula Elisabeth van Westrienen, Martijn F Pisters, Suze AJ Toonders, Marloes Gerrits, Cindy Veenhof, Niek J de Wit. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 08.05.2018.

Somatization disorders in dermatology.

PubMed

Gupta, Madhulika A

2006-02-01

This paper reviews a wide range of somatization-related symptoms that are encountered in dermatology. These include the unexplained cutaneous sensory syndromes especially the cutaneous dysesthesias associated with pain, numbness and pruritus; traumatic memories in post-traumatic stress disorder (PTSD) which are experienced on a sensory level as 'body memories' and may present as local or generalized pruritic states, urticaria and angioedema; and unexplained flushing reactions and profuse perspiration, in addition to unexplained exacerbations of stress-reactive dermatoses such as psoriasis and atopic eczema secondary to the autonomic hyperarousal in PTSD; classic 'pseudoneurologic' symptoms associated with dissociation including unexplained loss of touch or pain, in addition to the self-induced dermatoses such as dermatitis artefacta and trichotillomania that are encountered with dissociative states; and body dysmorphic disorder where the patient often presents with a somatic preoccupation involving the skin or hair.

Natural and Undetermined Sudden Death: Value of Post-Mortem Genetic Investigation

PubMed Central

Fernández-Falgueras, Anna; Sarquella-Brugada, Georgia; Cesar, Sergi; Mademont, Irene; Mates, Jesus; Pérez-Serra, Alexandra; Coll, Monica; Pico, Ferran; Iglesias, Anna; Tirón, Coloma; Allegue, Catarina; Carro, Esther; Gallego, María Ángeles; Ferrer-Costa, Carles; Hospital, Anna; Bardalet, Narcís; Borondo, Juan Carlos; Vingut, Albert; Arbelo, Elena; Brugada, Josep; Castellà, Josep; Medallo, Jordi; Brugada, Ramon

2016-01-01

Background Sudden unexplained death may be the first manifestation of an unknown inherited cardiac disease. Current genetic technologies may enable the unraveling of an etiology and the identification of relatives at risk. The aim of our study was to define the etiology of natural deaths, younger than 50 years of age, and to investigate whether genetic defects associated with cardiac diseases could provide a potential etiology for the unexplained cases. Methods and Findings Our cohort included a total of 789 consecutive cases (77.19% males) <50 years old (average 38.6±12.2 years old) who died suddenly from non-violent causes. A comprehensive autopsy was performed according to current forensic guidelines. During autopsy a cause of death was identified in most cases (81.1%), mainly due to cardiac alterations (56.87%). In unexplained cases, genetic analysis of the main genes associated with sudden cardiac death was performed using Next Generation Sequencing technology. Genetic analysis was performed in suspected inherited diseases (cardiomyopathy) and in unexplained death, with identification of potentially pathogenic variants in nearly 50% and 40% of samples, respectively. Conclusions Cardiac disease is the most important cause of sudden death, especially after the age of 40. Close to 10% of cases may remain unexplained after a complete autopsy investigation. Molecular autopsy may provide an explanation for a significant part of these unexplained cases. Identification of genetic variations enables genetic counseling and undertaking of preventive measures in relatives at risk. PMID:27930701

Screening for Chlamydia trachomatis in Egyptian women with unexplained infertility, comparing real-time PCR techniques to standard serology tests: case control study.

PubMed

Abdella, Rana M A; Abdelmoaty, Hatem I; Elsherif, Rasha H; Sayed, Ahmed Mahmoud; Sherif, Nadine Alaa; Gouda, Hisham M; El Lithy, Ahmed; Almohamady, Maged; Abdelbar, Mostafa; Hosni, Ahmed Naguib; Magdy, Ahmed; Ma, Youssef

2015-06-02

To study the prevalence of Chlamydia infection in women with primary and secondary unexplained infertility using ELISA technique for antibody detection and real time, fully automated PCR for antigen detection and to explore its association with circulating antisperm antibodies (ASA). A total of 50 women with unexplained infertility enrolled in this case control study and a control group of 44 infertile women with a known cause of infertility. Endocervical specimens were collected for Chlamydia antigen detection using PCR and serum samples for antibodies detection. Circulating anti-sperm antibodies were detected using sperm antibody Latex Agglutination tests. The overall prevalence of Chlamydial infection in unexplained infertility cases as detected by both ELISA and PCR was 40 % (20/50). The prevalence of current Chlamydial genital infection as detected by real-time PCR was only 6.0 % (3/50); two of which were also IgM positive. Prevalence of ASA was 6.0 % (3/50); all were sero-negative for anti-C.trachomatis IgM and were PCR negative. The incidence of Chlamydial infection in Egyptian patients with unexplained infertility is relatively high. In the setting of fertility investigations; screening for anti. C.trachomatis antibodies using ELISA, and treatment of positive cases should be considered. The presence of circulating ASA does not correlate with the presence of old or current Chlamydia infection in women with unexplained infertility.

Diagnosis and Tests: Evaluating a Fall or Risk of Falling

MedlinePlus

... Other Resources Caregiving How To's Tools & Tips Latest Research Getting More Help Related Topics Anemia Aneurysms Balance Problems Diabetes Fainting (Syncope) Foot Problems Fractures Osteoporosis Physical Activity Prevention Sleep Problems Stroke Join our e- ...

Hemodynamic and neurohormonal responses to extreme orthostatic stress in physically fit young adults

NASA Astrophysics Data System (ADS)

Grasser, E. K.; Goswami, N.; Rössler, A.; Vrecko, K.; Hinghofer-Szalkay, H.

2009-04-01

Blood pressure stability may be jeopardized in astronauts experiencing orthostatic stress. There is disagreement about cardiovascular and endocrine stress responses that emerge when a critical (presyncopal) state is reached. We studied hemodynamic and neurohormonal changes as induced by an orthostatic stress paradigm (head-up tilt combined with lower body negative pressure) that leads to a syncopal endpoint. From supine control to presyncope, heart rate increased by 78% and thoracic impedance by 12%. There was a 49% fall in stroke volume index, 19% in mean arterial blood pressure, 14% in total peripheral resistance index and 11% in plasma volume. Plasma norepinephrine rose by 107, epinephrine by 491, plasma renin activity by 167, and cortisol by 25%. Hemodynamic and hormonal changes of clearly different magnitude emerge in presyncope as compared to supine rest. Additional studies are warranted to reveal the exact time course of orthostatic changes up to syncopal levels.

Severe portopulmonary hypertension in congenital hepatic fibrosis.

PubMed

Hsu, Chen-Ming; Chiu, Cheng-Tang; Lien, Jau-Min; Ng, Kwai-Fong

2003-03-01

Portopulmonary hypertension is a rare complication of portal hypertension. Although epoprostenol infusion, nitric oxide inhalation, isosorbide-5-mononitrate, nitroglycerin, and calcium channel blockers may reduce pulmonary artery pressure in patients with portopulmonary hypertension, the prognosis remains poor. We present a case of congenital hepatic fibrosis associated with pulmonary hypertension. A 42-year-old man with congenital hepatic fibrosis visited our hospital with syncope. The man had suffered from breathlessness on exertion for 2 weeks before the episode of syncope. He also had a history of portal hypertension with documented gastric cardiac varices at the age of 28 years. Despite undergoing intensive care, the patient died 1 week after admission owing to severe right-sided heart failure. Autopsy revealed dilatation of the right atrium and right ventricle grossly and plexogenic pulmonary arteriopathy microscopically. Accurate diagnosis of portopulmonary hypertension requires awareness of the disease and a high index of suspicion when examining patients with portal hypertension and dyspnea.

Dance, Music, Meter and Groove: A Forgotten Partnership.

PubMed

Fitch, W Tecumseh

2016-01-01

I argue that core aspects of musical rhythm, especially "groove" and syncopation, can only be fully understood in the context of their origins in the participatory social experience of dance. Musical meter is first considered in the context of bodily movement. I then offer an interpretation of the pervasive but somewhat puzzling phenomenon of syncopation in terms of acoustic emphasis on certain offbeat components of the accompanying dance style. The reasons for the historical tendency of many musical styles to divorce themselves from their dance-based roots are also briefly considered. To the extent that musical rhythms only make sense in the context of bodily movement, researchers interested in ecologically valid approaches to music cognition should make a more concerted effort to extend their analyses to dance, particularly if we hope to understand the cognitive constraints underlying rhythmic aspects of music like meter and groove.

Dance, Music, Meter and Groove: A Forgotten Partnership

PubMed Central

Fitch, W. Tecumseh

2016-01-01

I argue that core aspects of musical rhythm, especially “groove” and syncopation, can only be fully understood in the context of their origins in the participatory social experience of dance. Musical meter is first considered in the context of bodily movement. I then offer an interpretation of the pervasive but somewhat puzzling phenomenon of syncopation in terms of acoustic emphasis on certain offbeat components of the accompanying dance style. The reasons for the historical tendency of many musical styles to divorce themselves from their dance-based roots are also briefly considered. To the extent that musical rhythms only make sense in the context of bodily movement, researchers interested in ecologically valid approaches to music cognition should make a more concerted effort to extend their analyses to dance, particularly if we hope to understand the cognitive constraints underlying rhythmic aspects of music like meter and groove. PMID:26973489

Syncope During Competitive Events: Interrogating Heart Rate Monitor Watches May Be Useful!

PubMed

Thabouillot, Oscar; Bostanci, Kevin; Bouvier, Francois; Dumitrescu, Nicolae; Stéfuriac, Maria; Paule, Philippe; Roche, Nicolas-Charles

2017-12-01

This is a case report of a 45-year-old man who reported complete amnesia during the very first kilometer of a 10-km run. He was wearing a heart rate monitor (HRM). The interrogation of his HRM watch showed 200 bpm tachycardia beginning in the first kilometer and increasing up to 220 bpm during the last kilometer. The patient was asked to wear a Holter-monitor (Holter Research Laboratory; Helena, Montana USA) electrocardiogram (ECG) while practicing a training session. This examination allowed for the diagnosis of an adrenergic paroxysmal atrial fibrillation (AF) with an impressive auriculo-ventricular conduction over 260 bpm. This case highlights that non-medical devices, such as connected watches, can be helpful to diagnose arrhythmias. Thabouillot O , Bostanci K , Bouvier F , Dumitrescu N , Stéfuriac M , Paule P , Roche NC . Syncope during competitive events: interrogating heart rate monitor watches may be useful! Prehosp Disaster Med. 2017;32(6):691-693.

Postural orthostatic tachycardia syndrome: Dental treatment considerations.

PubMed

Brooks, John K; Francis, Laurie A P

2006-04-01

Postural orthostatic tachycardia syndrome (POTS) is a chronic, relatively common autonomic disorder typically affecting younger females. It is distinguished by a dramatic increase in heart rate on the assumption of an upright posture from the supine position. The authors provide an overview of the demographics, clinical assessment, diagnostic features, differential diagnoses, pathogeneses and medical treatment of patients with POTS, with an emphasis on the clinical treatment of the dental patient affected by the syndrome. Patients frequently exhibit symptoms of lightheadedness, fatigue, palpitations and syncope. Patients with POTS may have Ehlers-Danlos syndrome, mitral valve prolapse, chronic fatigue syndrome or, rarely, the Brugada syndrome. Despite widespread dissemination of information regarding POTS in the medical literature, scant information on it has appeared in dental publications. Dentists need to be familiar with the clinical features of POTS and be prepared to treat patients at risk of developing syncope.

The problem of dizziness and syncope in old age: transient ischemic attacks versus hypersensitive carotid sinus reflex.

PubMed

Uesu, C T; Eisenman, J I; Stemmer, E A

1976-03-01

In the elderly, a transient ischemic attack (TIA) and a hypersensitive carotid sinus reflex (HCSR) often co-exist and can pose a diagnostic challenge. Seven cases are presented. HCSR is a relative condition; besides increased irritability of the receptor or target organs, susceptibility of the nerve center to ischemia probably is induced by a slow heart rate or low blood pressure in any patient with pre-existing occlusive cerebrovascular disease. Dizziness and syncope of this type represent hemodynamic TIA in contrast to thromboembolic TIA. The carotid sinus massage test is recommended for differentiating the two types of TIA; the treatments differ. At present there is no uniform management that can be applied to either TIA or HCSR routinely. Therefore, treatment should be approached on an individual basis, keeping in mind the different pathophysiologic factors operating in the specific patient.

Nursing management of reflex anoxic seizures in children.

PubMed

Patel, Neal; Kerr-Liddell, Rowan; Challis, Louise; Paul, Siba Prosad

2017-04-13

Children who present with transient loss of consciousness (T-LOC) are often first seen in emergency departments (EDs). Reflex anoxic seizure (RAS), vasovagal syncope and prolonged respiratory apnoea are benign, syncopal events that can be generally managed by explanation and reassurance. RAS is a short, paroxysmal, self-reverting episode of asystole that is triggered by pain, fear or anxiety and is caused by increased vagal response. It is an important differential diagnosis in pre-school age children who present with T-LOC, but is often underdiagnosed and can sometimes be misdiagnosed as epilepsy. Nurses working in EDs are among the first healthcare professionals to see children in acute settings and should therefore be aware of RAS, the presenting features and management options. This article discusses the epidemiology, pathophysiology and management of RAS, includes an illustrative case study and discusses the role of ED nurses.

Prolonged ictal aphasia: a diagnosis to consider.

PubMed

Herskovitz, Moshe; Schiller, Yitzhak

2012-11-01

Aphasia is a common symptom encountered by clinical neurologists. It is usually caused by strokes or lesions involving language regions of the brain, yet prolonged aphasia is rarely the sole manifestation of a simple partial status epilepticus. We report six patients, who suffered from prolonged ictal aphasia. All but one patient had a structural lesion in the left hemisphere, only three suffered from clinical seizures during or shortly prior to the aphasic episode. All patients had ictal patterns on the electroencephalogram (EEG), four of whom had periodic lateralized epileptiform discharges, and five showed frequent recurrent electrographic seizures during the aphasic state. The aphasia lasted several days in all patients, and it resolved after administration of antiepileptic drug treatment. In conclusion, prolonged ictal aphasia is a rare but important treatable cause of aphasia. Surface EEG recordings should be obtained in all patients with unexplained prolonged aphasia to diagnose this rare but treatable entity. Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.

Listeria monocytogenes: a foodborne pathogen.

PubMed Central

Farber, J M; Losos, J Z

1988-01-01

Listeriosis, caused by Listeria monocytogenes, appears to be increasing in incidence worldwide. The disease is of great concern to the food industry. A recent outbreak in California was linked to the consumption of Mexican-style soft cheese and involved more than 300 cases, 30% of which were fatal. L. monocytogenes can be found in a variety of dairy products, leafy vegetables, fish and meat products. It can grow in refrigerated foods and is more heat resistant than most vegetative microbes. The epidemiologic features of listeriosis are poorly understood, and the minimum infectious dose is unknown. Those predisposed to listeriosis include immunocompromised people and pregnant women and their fetuses. Meningitis, spontaneous abortion and septicemia are the primary manifestations of the disease. Early recognition is critical for successful treatment, and ampicillin is the preferred drug. Listeriosis should be considered in any febrile patient with neurologic symptoms of unknown origin, as well as in women with unexplained recurrent miscarriages, premature labour or fetal death. A food source should be the prime suspect if any isolated case or outbreak occurs. PMID:3124948

A novel lymphocyte signaling defect: trk A mutation in the syndrome of congenital insensitivity to pain and anhidrosis (CIPA).

PubMed

Melamed, I; Levy, J; Parvari, R; Gelfand, E W

2004-07-01

Congenital insensitivity to pain with anhidrosis is a syndrome characterized by loss of pain and sensation. The condition frequently evolves into deep wounds and prolonged healing times. Anhidrosis is another prominent component of the disorder. Often associated with recurrent episodes of unexplained fever, it can result in patient mortality. Recent investigations point to Trk A, the high affinity receptor for nerve growth factor (NGF), as a candidate for the site of the mutation that causes the disorder. Functional NGF receptors, such as Trk A and the Trk family of tyrosine kinases, are essential for NGF signaling of human lymphocytes. In this study, we demonstrated that the presence of a trk A mutation in patient B cells results in a novel lymphocyte signaling defect. In these B cells, NGF failed to induce Trk A phosphorylation, cytoskeleton assembly, or MAP kinase activation. These abnormalities may explain some of the clinical features of the disease.

Vascular type Ehlers-Danlos Syndrome with fatal spontaneous rupture of a right common iliac artery dissection: case report and review of literature

PubMed Central

Abayazeed, Aly; Hayman, Emily; Moghadamfalahi, Mana; Cain, Darren

2014-01-01

Vascular Ehlers-Danlos Syndrome (previously Ehlers-Danlos IV) is a rare autosomal dominant collagen vascular disorder caused by a 2q31 COL3A1 gene mutation encoding pro-alpha1 chain of type III collagen (in contrast to classic Ehlers-Danlos, caused by a COL5A1 mutation). The vascular type accounts for less than 4% of all Ehlers-Danlos cases and usually has a poor prognosis due to life threatening vascular ruptures and difficult, frequently unsuccessful surgical and vascular interventions. In 70% of cases, vascular rupture or dissection, gastrointestinal perforation, or organ rupture is a presenting sign. We present a case of genetically proven vascular Ehlers-Danlos with fatal recurrent retroperitoneal hemorrhages secondary to a ruptured right common iliac artery dissection in a 30-year-old male. This case highlights the need to suspect collagen vascular disorders when a young adult presents with unexplained retroperitoneal hemorrhage, even without family history of such diseases. PMID:24967021

Extrinsic allergic alveolitis caused by misting fountains.

PubMed

Koschel, Dirk; Stark, Wolfram; Karmann, Fritz; Sennekamp, Jochen; Müller-Wening, Dietrich

2005-08-01

Recently, an increasing number of patients were presented to our clinics with febrile and respiratory symptoms associated with exposure to a new type of domestic ultrasonic humidifier. We report on 11 patients who developed recurrent episodes of fever, cough and dyspnea after repeated exposure to ultrasonic misting fountains at home. A diagnosis of extrinsic allergic alveolitis (EAA) or toxic alveolitis was made on the basis of the history and the clinical, radiological, laboratory and immunological findings. Eight patients were subjected to inhalative challenge tests with their own ultrasonic misting fountains, and all of them exhibited positive reactions. Nine patients were diagnosed with an EAA (humidifier lung) and two patients with a toxic alveolitis (humidifier fever). This study demonstrates the potential for ultrasonic misting fountains to cause illness in the home. In view of the increasing popularity of these devices, humidifier lung and humidifier fever should be considered in the differential diagnosis of patients with unexplained pulmonary or flu-like illnesses with fever.

Prevalence of subclinical and undiagnosed overt hypothyroidism in a pregnancy loss clinic.

PubMed

Khalid, A S; Joyce, C; O'Donoghue, K

2013-04-01

Recent studies have associated pregnancy loss with subclinical hypothyroidism, defined as elevated thyroid-stimulating-hormone level, with normal free thyroxine. In overt hypothyroidism, the free thyroxine is low. Subclinical and overt hypothyroidism occurs in 0.25-2.5% and 0.2-0.3% of pregnancies respectively. We examined the prevalence of subclinical and undiagnosed overt hypothyroidism in women with recurrent miscarriage, late miscarriage and stillbirth attending the Pregnancy Loss Clinic. Data was collected from the Pregnancy Loss Clinic records. Women with sporadic miscarriages, autoimmune disorders, thrombophilias and known hypothyroidism were excluded. Two-hundred-and-sixty-two women were included. Median maternal age was 35 years (range 18-47). Subclinical and undiagnosed overt hypothyroidism was found in 11.45% of women. Twenty-two women (8.39%) had subclinical hypothyroidism, eight (3.05%) had undiagnosed overt hypothyroidism. Results were compared to women with ongoing pregnancies. A proportion of women attending the clinic had subclinical or undiagnosed overt hypothyroidism, raising the suspicion of causation in unexplained pregnancy loss.

Red or uncomfortable eye.

PubMed Central

Davey, C.; Hurwitz, B.

1992-01-01

1. A red, uncomfortable eye may be accompanied by other symptoms such as blurred, decreased, or double vision, haloes, photophobia, pain or discharge. 2. A careful history and brief systematic examination will sort out most problems. 3. Examine eyelids, the conjunctivae and corneas. Checking visual acuity is often important. 4. The most common underlying causes can usually be managed within general practice, though a few patients will require urgent eye assessment, or routine referral to ophthalmic outpatients. 5. The following are typical eye problems which require urgent referral: History of pain as opposed to discomfort, Trauma including foreign bodies, chemicals and suspected penetrating injury, Unexplained drop in visual acuity of two lines or more in a painful eye. Specific conditions: preseptal cellulitis, herpes simplex ulcer, scleritis, orbital cellulitis, herpes zoster, bacterial corneal ulcer, dacryocystitis. 6. The following are typical problems which may require routine referral: Persistence of the problem not relieved by simple measures, Recurrent disorders of uncertain diagnosis, Eyelid swelling such as chalazion, cysts, basal cell carcinoma, Gradual loss of vision, for example cataract, macular degeneration. PMID:1345157

[Tubulointerstitial nephritis with uveitis (TINU) syndrome. A relatively rare rheumatological differential diagnosis with unexplained uveitis].

PubMed

Häusler, U; Guminski, B; Helmchen, U; Kisters, K; Heinz, C; Braun, J

2013-05-01

The tubulo-interstitial nephritis and uveitis (TINU) syndrome, first described in 1975, is a rare disease most probably of autoimmune origin that is characterized by unilateral or bilateral uveitis and tubulointerstitial nephritis. Most patients are adolescents and it is sometimes associated with other autoimmune diseases, such as spondyloarthritis, rheumatoid arthritis and hyperthyroidosis. This article reports the case of a 43-year-old female patient who presented with refractory recurrent bilateral uveitis despite therapy with high doses of corticosteroids in combination with cyclosporin. When the patient was referred to this hospital for rheumatological examination after almost 1 year of therapy, mild renal insufficiency and proteinuria were found. The kidney biopsy revealed interstitial nephritis, partly crescent-shaped and partly chronic. A diagnosis of TINU syndrome was made and treatment with adalimumab in combination with methotrexate was started. The favorable clinical outcome indicated that tumor necrosis factor (TNF) alpha may play an important role in the pathogenesis of TINU syndrome.

Endogenous circadian rhythm in vasovagal response to head-up tilt

PubMed Central

Hu, Kun; Scheer, Frank AJL; Laker, Michael; Smales, Carolina; Shea, Steven A

2011-01-01

Background The incidence of syncope exhibits a daily pattern with more occurrences in the morning, possibly due to influences from the endogenous circadian system and/or the daily pattern of behavioral/emotional stimuli. This study tested the hypothesis that the circadian system modulates cardiovascular responses to postural stress, leading to increased susceptibility to syncope at specific times of day. Methods and Results Twelve subjects underwent a 13-day in-laboratory protocol, in which subjects’ sleep-wake cycles were adjusted to 20 hours for 12 cycles. A 15-minute title-table test (60° head-up) was performed ~4.5 hours after scheduled awakening in each cycle so that twelve tests in each subject were distributed evenly across the circadian cycle. Out of 144 tests, signs/symptoms of presyncope were observed in 21 tests in 6 subjects. These presyncope events displayed a clear circadian rhythm (P=0.028) with 17 cases (81%) in the circadian phase range corresponding to ~22:30-10:30 (4.25 times of the probability from the other half of the circadian cycle). Significant circadian rhythms were also observed in hemodynamic and autonomic function markers (blood pressure, heart rate, epinephrine, norepinephrine, and indices of cardiac vagal tone) that may underlie the circadian rhythm of presyncope susceptibility. Conclusion The circadian system affects cardiovascular responses to postural stressors resulting in greater susceptibility to presyncope during the biological night. This finding suggests that night-shift workers and people with disrupted sleep at night may have great risk of syncope due to their exposure to postural stressors during the biological night. PMID:21339480

Are Compression Stockings an Effective Treatment for Orthostatic Presyncope?

PubMed Central

Protheroe, Clare Louise; Dikareva, Anastasia; Menon, Carlo; Claydon, Victoria Elizabeth

2011-01-01

Background Syncope, or fainting, affects approximately 6.2% of the population, and is associated with significant comorbidity. Many syncopal events occur secondary to excessive venous pooling and capillary filtration in the lower limbs when upright. As such, a common approach to the management of syncope is the use of compression stockings. However, research confirming their efficacy is lacking. We aimed to investigate the effect of graded calf compression stockings on orthostatic tolerance. Methodology/Principal Findings We evaluated orthostatic tolerance (OT) and haemodynamic control in 15 healthy volunteers wearing graded calf compression stockings compared to two placebo stockings in a randomized, cross-over, double-blind fashion. OT (time to presyncope, min) was determined using combined head-upright tilting and lower body negative pressure applied until presyncope. Throughout testing we continuously monitored beat-to-beat blood pressures, heart rate, stroke volume and cardiac output (finger plethysmography), cerebral and forearm blood flow velocities (Doppler ultrasound) and breath-by-breath end tidal gases. There were no significant differences in OT between compression stocking (26.0±2.3 min) and calf (29.3±2.4 min) or ankle (27.6±3.1 min) placebo conditions. Cardiovascular, cerebral and respiratory responses were similar in all conditions. The efficacy of compression stockings was related to anthropometric parameters, and could be predicted by a model based on the subject's calf circumference and shoe size (r = 0.780, p = 0.004). Conclusions/Significance These data question the use of calf compression stockings for orthostatic intolerance and highlight the need for individualised therapy accounting for anthropometric variables when considering treatment with compression stockings. PMID:22194814

Gardner-Diamond syndrome: Difficulties in the management of patients with unexplained medical symptoms

PubMed Central

Meeder, Robert; Bannister, Susan

2006-01-01

The case of an adolescent girl who presented with unexplained bruising is reported. Subsequent investigations failed to elucidate an organic etiology. The diagnosis of Gardner-Diamond syndrome – a syndrome of predictable bruising preceded by pain and warmth at the bruise site, often associated with physical or psychosocial stress – was made. In the present report, the authors use their experience with this rare syndrome to highlight some important ethical and practical considerations with regard to investigation, treatment and communication in illnesses with unexplained medical symptoms. PMID:19030312

A case of anorexia nervosa in an elderly man.

PubMed

Malik, Fahd; Wijayatunga, Uditha; Bruxner, George M

2014-06-01

To explore aspects of anorexia nervosa occurring in older populations, especially men, by reviewing the literature and presenting a case study of an elderly man with unexplained vomiting and weight loss. The literature is reviewed and an illustrative case study of an elderly man with unexplained vomiting and weight loss is described. Anorexia nervosa is an uncommon cause of unexplained weight loss in the elderly, but may be under-recognized and associated with a high level of mortality. © The Royal Australian and New Zealand College of Psychiatrists 2014.

Limitations of Current AHA Guidelines and Proposal of New Guidelines for the Preparticipation Examination of Athletes.

PubMed

Dunn, Tim P; Pickham, David; Aggarwal, Sonya; Saini, Divya; Kumar, Nikhil; Wheeler, Matthew T; Perez, Marco; Ashley, Euan; Froelicher, Victor F

2015-11-01

To examine the prevalence of athletes who screen positive with the preparticipation examination guidelines from the American Heart Association, the AHA 12-elements, in combination with 3 screening electrocardiogram (ECG) criteria. Observational cross-sectional study. Stanford University Sports Medicine Clinic. Total of 1596 participants, including 297 (167 male; mean age, 16.2 years) high school athletes, 1016 (541 male; mean age, 18.8 years) collegiate athletes, and 283 (mean age, 26.3 years) male professional athletes. Athletes were screened using the 8 personal and family history questions from the AHA 12-elements. Electrocardiograms were obtained for all participants and interpreted using Seattle criteria, Stanford criteria, and European Society of Cardiology (ESC) recommendations. Approximately one-quarter of all athletes (23.8%) had at least 1 positive response to the AHA personal and family history elements. High school and college athletes had similar rates of having at least 1 positive response (25.9% vs 27.4%), whereas professional athletes had a significantly lower rate of having at least 1 positive response (8.8%, P < 0.05). Females reported more episodes of unexplained syncope (11.4% vs 7.5%, P = 0.017) and excessive exertional dyspnea with exercise (11.1% vs 6.1%, P = 0.001) than males. High school athletes had more positive responses to the family history elements when compared with college athletes (P < 0.05). The percentage of athletes who had an abnormal ECG varied between Seattle criteria (6.0%), Stanford criteria (8.8%), and ESC recommendations (26.8%). Many athletes screen positive under current screening recommendations, and ECG results vary widely by interpretation criteria. In a patient population without any adverse cardiovascular events, the currently recommended AHA 12-elements have an unacceptably high rate of false positives. Newer screening guidelines are needed, with fewer false positives and evidence-based updates.

Vaccinating Your Preteen: Addressing Common Concerns

MedlinePlus

... to sit for 15 minutes after getting any​ shot in case your child faints (syncope). Staying seated for 15 ... mild side effects that can occur after receiving shots. Why is more than one dose of vaccine needed? HPV vaccine: It is ...

Unexplained chronic leukopenia treated with oral iron supplements.

PubMed

Abuirmeileh, Ayman; Bahnassi, Anas; Abuirmeileh, Amjad

2014-04-01

A 67-year-old woman known to have iron deficiency anemia and persistent unexplained chronic leukopenia was cared for by our medical center for about 16 years. During this period she was examined thoroughly and diagnosed to have chronic idiopathic neutropenia (also known as chronic benign neutropenia). Her iron deficiency was attributed to nutritional factors and she was non-compliant with her oral iron supplements. The patient fully received her iron supplement medication by nursing staff for two and a half months during an unexpected prolonged hospital stay after her suffering an acute ischemic cerebrovascular accident. An astonishing outcome was that in addition to having her iron deficiency anemia treated, her long-term unexplained neutropenia was also corrected. Some patients diagnosed with chronic idiopathic neutropenia and clinically present as having unexplained chronic neutropenia might actually be suffering from a form of not yet described iron deficiency induced neutropenia.

Outpatient Management of Emergency Department Patients With Acute Pulmonary Embolism: Variation, Patient Characteristics, and Outcomes.

PubMed

Vinson, David R; Ballard, Dustin W; Huang, Jie; Reed, Mary E; Lin, James S; Kene, Mamata V; Sax, Dana R; Rauchwerger, Adina S; Wang, David H; McLachlan, D Ian; Pleshakov, Tamara S; Silver, Matthew A; Clague, Victoria A; Klonecke, Andrew S; Mark, Dustin G

2017-12-13

Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility-level variation of outpatient pulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge. The Management of Acute Pulmonary Embolism (MAPLE) study is a retrospective cohort study of patients with acute pulmonary embolism undertaken in 21 community EDs from January 2013 to April 2015. We gathered demographic and clinical variables from comprehensive electronic health records and structured manual chart review. We used multivariable logistic regression to assess the association between patient characteristics and home discharge. We report ED length of stay, consultations, 5-day pulmonary embolism-related return visits and 30-day major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. Of 2,387 patients, 179 were discharged home (7.5%). Home discharge varied significantly between EDs, from 0% to 14.3% (median 7.0%; interquartile range 4.2% to 10.9%). Median length of stay for home discharge patients (excluding those who arrived with a new pulmonary embolism diagnosis) was 6.0 hours (interquartile range 4.6 to 7.2 hours) and 81% received consultations. On adjusted analysis, ambulance arrival, abnormal vital signs, syncope or presyncope, deep venous thrombosis, elevated cardiac biomarker levels, and more proximal emboli were inversely associated with home discharge. Thirteen patients (7.2%) who were discharged home had a 5-day pulmonary embolism-related return visit. Thirty-day major hemorrhage and recurrent venous thromboembolism were uncommon and similar between patients hospitalized and those discharged home. All-cause 30-day mortality was lower in the home discharge group (1.1% versus 4.4%). Home discharge of ED patients with acute pulmonary embolism was uncommon and varied significantly between facilities. Patients selected for outpatient management had a low incidence of adverse outcomes. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Disorders of lipid metabolism in muscle.

PubMed

Di Mauro, S; Trevisan, C; Hays, A

1980-01-01

At rest and during sustained exercise, lipids are the main source of energy for muscle. Free fatty acids become available to muscle from plasma free fatty acids and triglycerides, and from intracellular triglycride lipid droplets. Transport of long-chain fatty acyl groups into the mitochondria requires esterification and de-esterification with carnitine by the "twin" enzymes carnitine palmityltransferase (CPT) I and II, bound to the outer and inner faces of the inner mitochondrial membrane. Carnitine deficiency occurs in two clinical syndromes. (1) In the myopathic form, there is weakness; muscle biopsy shows excessive accumulation of lipid droplets; and the carnitine concentration is markedly decreased in muscle but normal in plasma. (2) In the systemic form, there are weakness and recurrent episodes of hepatic encephalopathy; muscle biopsy shows lipid storage; and the carnitine concentration is decreased in muscle, liver, and plasma. The etiology of carnitine deficiency is not known in either the myopathic or the systemic form, but administration of carnitine or corticosteroids has been beneficial in some patients. "Secondary" carnitine deficiency may occur in patients with malnutrition, liver disease, chronic hemodialysis, and, possibly, mitochondrial disorders. CPT deficiency causes recurrent myoglobinuria, usually precipitated by prolonged exercise or fasting. Muscle biopsy may be normal or show varying degrees of lipid storage. Genetic transmission is probably autosomal recessive, but the great male predominance (20/21) remains unexplained. In many cases, lipid storage myopathy is not accompanied by carnitine or CPT deficiency, and the biochemical error remains to be identified.

SLC34A3 Intronic Deletion in an Iranian Kindred with Hereditary Hypophosphatemic Rickets with Hypercalciuria and Review of Reported Cases.

PubMed

Hasani-Ranjbar, Shirin; Ejtahed, Hanieh Sadat; Amoli, Mahsa M; Bitarafan, Fatemeh; Qorbani, Mostafa; Soltani, Akbar; Yarjoo, Bahareh

2018-05-29

Hereditary Hypophosphatemic Rickets with Hypercalciuria (HHRH) is a very rare inheritable hypophosphatemic rickets/osteomalacia characterized by decreased renal phosphate reabsorption, hypophosphatemia, vitamin D refractory rickets, hyperphosphaturia, hypercalciuria, elevated circulating 1, 25-dihydroxy vitamin D levels and low serum parathyroid hormone (PTH) levels, leading to growth retardation, limb deformities, bone pain, muscle weakness, rickets and osteomalacia. Biallelic mutations in SLC34A3/NPT2c gene are responsible for the occurrence of the disease. In this paper we describe the clinical examination, biochemical profile and gene analysis of Iranian kindred with a 101bp deletion in SLC34A3 gene. 12 members of a family of previously reported patient with HHRH (3 homozygote and 7 heterozygote) and 10 healthy controls were evaluated. All patients had significantly increased risk of kidney stone formation, bone deformities and short stature compared with unrelated healthy controls. The heterozygous patients displayed milder clinical symptoms compared with homozygous patients. These patients displayed mild or no hypophosphatemia and they did not develop skeletal deformities. Recurrent renal stones and hypercalciuria were the main presentations of heterozygous patients which could be confused with familial hypercalciuria. In addition, biochemical analysis showed significantly low serum sodium level and elevated alkaline phosphatase in patients. Genetic counseling and screening for SLC34A3 mutations can be helpful in adult onset phenotype with unexplained osteoporosis, bone deformities and especial recurrent renal stones. In subjects with vitamin D deficiency the results should be interpreted cautiously.

Unexplained cough: it is time to rule out Sjogren's syndrome.

PubMed

Koslow, Matthew; Kivity, Shaye; Vishnevskia-Dai, Vicktoria; Ben-Dov, Issahar

2018-05-01

Sjogren's syndrome is associated with chronic cough, but sicca symptoms are missing from cough evaluation guidelines. We evaluated patients with unexplained cough for undiagnosed Sjogren's syndrome. Patients referred to our pulmonary clinic (Sheba Medical Center, 2009 to 2012) with unexplained cough and concomitant dry eyes were selected for evaluation. Unexplained cough was defined as chronic cough of unknown etiology despite algorithm-based evaluation and treatment. Patients were evaluated in a dedicated clinic by a pulmonologist, rheumatologist, and ophthalmologist specializing in autoimmune disease. Patients completed the Leicester Cough Questionnaire, spirometry, antibody testing for anti Ro/La, ophthalmologic examination with visual acuity, eyelid, ocular surface fluorescein staining, tear break-up time and Schirmer's test, full slit lamp, and fundus examinations. Four-year follow-up was conducted by telephone questionnaire. We identified 24 patients among which 22 (21 females) agreed for evaluation. Eight patients (36%), seven initially, and one during follow-up were diagnosed with Sjogren's syndrome (SS) (six secondary and two primary SS). At 4-year follow-up, cough tended to persist and improve in only 37% with SS. These include 2 (Scl and RA) who received rituximab and 1 (stage 1 sarcoidosis) with spontaneous improvement. In contrast, cough improved in most (64%) patients without SS; the majority (eight/nine) report intensified disease-specific treatment (five allergic and three GERD). We describe patients in whom unexplained chronic cough was associated with dry eyes. Focused workup revealed undiagnosed Sjogren's syndrome in 36%. Dry eyes, with or without SS, is under-recognized and should be added to diagnostic algorithms for unexplained cough.

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2010 CFR

2010-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2013 CFR

2013-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2014 CFR

2014-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2011 CFR

2011-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

38 CFR 3.212 - Unexplained absence for 7 years.

Code of Federal Regulations, 2012 CFR

2012-07-01

... continued and unexplained absence of any individual from his or her home and family for a period of 7 years or more and that a diligent search disclosed no evidence of his or her existence after the date of...

Unexplained Absences and Risk of Death and Injury Among Nursing Home Residents: A Systematic Review.

PubMed

Woolford, Marta H; Weller, Carolina; Ibrahim, Joseph E

2017-04-01

Unexplained absence of nursing home (NH) residents is one of the most challenging issues related to the care of older people. The aim of this review was to examine the death and injury outcomes of unexplained absence of NH residents. We searched MEDLINE, CINAHL, EMBASE, PsycINFO, AgeLine, and Cochrane Library to identify qualitative and quantitative studies published in the English language. Data on death and injury were collated, and aggregate proportions were calculated where possible. Nine studies were identified; most (n = 6) were conducted in the United States. Persons with dementia formed the study population in all studies. There were 1440 individual unexplained absences reported across the 9 studies. We calculated a rate of 82 deaths and 61 injuries per 1000 incidents of unexplained absence. Extreme temperatures were the most common cause of death. Most individuals left by foot, and were found within a 1-mile radius of place last seen in green vegetation and waterways. This review provides valuable insight into death and injury outcomes. Further studies are recommended to improve understanding and prevent adverse outcomes. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Physician Satisfaction in Treating Medically Unexplained Symptoms.

PubMed

Brauer, Simon G; Yoon, John D; Curlin, Farr A

2017-05-01

To determine whether treating conditions having medically unexplained symptoms is associated with lower physician satisfaction and higher ascribed patient responsibility, and to determine whether higher ascribed patient responsibility is associated with lower physician satisfaction in treating a given condition. We surveyed a nationally representative sample of 1504 US primary care physicians. Respondents were asked how responsible patients are for two conditions with more-developed medical explanations (depression and anxiety) and two conditions with less-developed medical explanations (chronic back pain and fibromyalgia), and how much satisfaction they experienced in treating each condition. We used Wald tests to compare mean satisfaction and ascribed patient responsibility between medically explained conditions and medically unexplained conditions. We conducted single-level and multilevel ordinal logistic models to test the relation between ascribed patient responsibility and physician satisfaction. Treating medically unexplained conditions elicited less satisfaction than treating medically explained conditions (Wald P < 0.001). Physicians attribute significantly more patient responsibility to the former (Wald P < 0.005), although the magnitude of the difference is small. Across all four conditions, physicians reported experiencing less satisfaction when treating symptoms that result from choices for which patients are responsible (multilevel odds ratio 0.57, P = 0.000). Physicians experience less satisfaction in treating conditions characterized by medically unexplained conditions and in treating conditions for which they believe the patient is responsible.

Case report on the non-operative management of a retrievable inferior vena cava filter perforating the duodenum.

PubMed

Fernandez-Moure, Joseph S; Kim, Keemberly; Zubair, M Haseeb; Rosenberg, Wade R

2017-01-01

Deep vein thrombosis (DVT) continues to be a significant source of morbidity for surgical patients. Placement of a retrievable inferior vena cava (IVC) filter is used when patients have contraindications to anticoagulation or recurrent pulmonary embolism despite therapeutic anticoagulation. Although retrievable IVC filters are often used, they carry a unique set of risks. A 67-year-old man presents to the Emergency Room (ER) following large volume melena and complaining of syncope. One year prior, the patient had been diagnosed with Glioblastoma multiforme, for which he underwent a craniotomy with near-total resection of the mass. He subsequently developed a deep vein thrombosis and underwent placement of a retrievable inferior vena cava (IVC) filter. Computerized tomography (CT) and esophagogastroduodenoscopy showed duodenal perforation by the retrievable IVC filter. The filter was successfully retrieved through an endovascular approach. Retrievable IVC filter placement is the preferred method of pulmonary embolism prevention in patients with significant risk for bleeding. Duodenal perforation by a retrievable IVC filter is a rare and serious complication. It is usually managed surgically, but can also be managed non-operatively. For patients with significant comorbidities or patients who are poor surgical candidates, non-operative management with close monitoring can serve as an initial approach to the patient with a caval enteric perforation secondary to a retrievable IVC filter. Copyright © 2017. Published by Elsevier Ltd.

49 CFR 391.41 - Physical qualifications for drivers.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea... clinical diagnosis of rheumatic, arthritic, orthopedic, muscular, neuromuscular, or vascular disease which..., nervous, organic, or functional disease or psychiatric disorder likely to interfere with his/her ability...

Comprehensive analysis of immune, extracellular matrices and pathogens profile in lung granulomatosis of unexplained etiology.

PubMed

da Costa Souza, Paola; Dondo, Patrícia Suemi; Souza, Gabriela; Lopes, Deborah; Moscardi, Marcel; de Miranda Martinho, Vinicius; de Mattos Lourenço, Rodolfo Daniel; Prieto, Tabatha; Balancin, Marcelo Luiz; Assato, Aline Kawassaki; Teodoro, Walcy Rosolia; Rodrigues, Silvia; Lima, Mariana; Castellano, Maria Vera; Coletta, Ester; Parra, Edwin Roger; Capelozzi, Vera Luiza

2018-05-01

This study analyzed the type 1 and type 2T helper (Th1/Th2) cytokines (including interleukins), immune cellular, matrix profile, and pathogens in granulomas with unexplained etiology compared to those with infectious and noninfectious etiology. Surgical lung biopsies from 108 patients were retrospectively reviewed. Histochemistry, immunohistochemistry, immunofluorescence, morphometry and polymerase chain reaction were used, respectively, to evaluate total collagen and elastin fibers, collagen I and III, immune cells, cytokines, matrix metalloproteinase-9, myofibroblasts, and multiple usual and unusual pathogens. No relevant polymerase chain reaction expression was found in unexplained granulomas. A significant difference was found between the absolute number of eosinophils, macrophages, and lymphocytes within granulomas compared to uninvolved lung tissue. Granulomas with unexplained etiology (UEG) presented increased number of eosinophils and high expression of interleukins (ILs) IL-4/IL-5 and transforming growth factor-β. In sarcoidosis, CD4/CD8 cell number was significantly higher within and outside granulomas, respectively; the opposite was detected in hypersensitivity pneumonitis. Again, a significant difference was found between the high number of myofibroblasts and matrix metalloproteinase-9 in UEG, hypersensitivity pneumonitis, and sarcoidosis compared to granulomas of tuberculosis. Granulomas of paracoccidioisis exhibited increased type I collagen and elastic fibers. Th1 immune cellular profile was similar among granulomas with unexplained, infectious, and noninfectious etiology. In contrast, modulation of Th2 and matrix remodeling was associated with more fibroelastogenesis and scarring of lung tissue in UEG compared to infectious and noninfectious. We concluded that IL-4/IL-5 and transforming growth factor-β might be used as surrogate markers of early fibrosis, reducing the need for genotyping, and promise therapeutic target in unexplained granulomas. Copyright © 2018 Elsevier Inc. All rights reserved.

Sexual function in infertile women with polycystic ovary syndrome and unexplained infertility.

PubMed

Diamond, Michael P; Legro, Richard S; Coutifaris, Christos; Alvero, Ruben; Robinson, Randal D; Casson, Peter A; Christman, Gregory M; Huang, Hao; Hansen, Karl R; Baker, Valerie; Usadi, Rebecca; Seungdamrong, Aimee; Bates, G Wright; Rosen, R Mitchell; Schlaff, William; Haisenleder, Daniel; Krawetz, Stephen A; Barnhart, Kurt; Trussell, J C; Santoro, Nanette; Eisenberg, Esther; Zhang, Heping

2017-08-01

While female sexual dysfunction is a frequent occurrence, characteristics in infertile women are not well delineated. Furthermore, the impact of infertility etiology on the characteristics in women with differing androgen levels observed in women with polycystic ovary syndrome and unexplained infertility has not been assessed. The objective of the study was to determine the characteristics of sexual dysfunction in women with polycystic ovary syndrome and unexplained infertility. A secondary data analysis was performed on 2 of Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Networks clinical trials: Pregnancy in Polycystic Ovary Syndrome Study II and Assessment of Multiple Intrauterine Gestations From Ovarian Stimulation. Both protocols assessed female sexual function using the Female Sexual Function Inventory and the Female Sexual Distress Scale. Women with polycystic ovary syndrome had higher weight and body mass index than women with unexplained infertility (each P < .001), greater phenotypic (Ferriman-Gallwey hirsutism score, sebum score, and acne score; each P < .001), and hormonal (testosterone, free testosterone, and dehydroepiandrosterone; each P < .001) evidence of androgen excess. Sexual function scores, as assessed by the Female Sexual Function Inventory, were nearly identical. The Female Sexual Distress Scale total score was higher in women with polycystic ovary syndrome. The mean Female Sexual Function Inventory total score increased slightly as the free androgen index increased, mainly as a result of the desire subscore. This association was more pronounced in the women with unexplained infertility. Reproductive-age women with infertility associated with polycystic ovary syndrome and unexplained infertility, despite phenotypic and biochemical differences in androgenic manifestations, do not manifest clinically significant differences in sexual function. Copyright © 2017 Elsevier Inc. All rights reserved.

[Blood-injection-injury phobia: Physochophysiological and therapeutical specificities].

PubMed

Ducasse, D; Capdevielle, D; Attal, J; Larue, A; Macgregor, A; Brittner, M; Fond, G

2013-10-01

Seventy-five percent of patients with blood-injection-injury phobia (BII-phobia) report a history of fainting in response to phobic stimuli. This specificity may lead to medical conditions remaining undiagnosed and untreated, incurring considerable cost for the individual and society. The psychophysiology of BII-phobia remains poorly understood and the literature on effective treatments has been fairly sparse. Aims of the systematic review: to synthesize the psychophysiology of BII-phobia and to propose a systematic review of the literature on effectiveness of different treatments evaluated in this indication. Firstly, the most distinct feature of the psychophysiology of BII-phobia is its culmination in a vasovagal syncope, which has been described as biphasic. The initial phase involves a sympathetic activation as is typically expected from fear responses of the fight-flight type. The second phase is characterized by a parasympathetic activation leading to fainting, which is associated with disgust. Subjects with syncope related to BII-phobia have an underlying autonomic dysregulation predisposing them to neurally mediated syncope, even in the absence of any blood or injury stimulus. Many studies report that BII-phobic individuals have a higher level of disgust sensitivity than individuals without any phobia. Secondly, behavioral psychotherapy techniques such as exposure only, applied relaxation, applied tension, and tension only, have demonstrated efficacy with no significant difference between all these techniques. The disgust induction has not improved effectiveness of exposure. We have explained the psychophysiology of BII-phobia, the understanding of which is required to study and validate specific techniques, in order to improve the prognosis of this disorder, which is a public health issue. Copyright © 2012 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.

EMS Activations for School-Aged Children From Public Buildings, Places of Recreation or Sport, and Health Care Facilities in Pennsylvania.

PubMed

Catherine, Andrew T; Olympia, Robert P

2016-06-01

To determine the etiology of emergency medical services (EMS) activations in 2011 to public buildings, places of recreation or sport, and health care facilities involving children aged 5 to 18 years in Pennsylvania. Electronic records documenting 2011 EMS activations as provided by the Pennsylvania Department of Health's Bureau of EMS were reviewed. Data elements (demographics, dispatch complaint, mechanism of injury, primary assessment) from patients aged 5 to 18 years involved in an EMS response call originating from either a public building, a place of recreation and sport, or health care facility were analyzed. A total of 12,289 records were available for analysis. The most common primary assessments from public buildings were traumatic injury, behavioral/psychiatric disorder, syncope/fainting, seizure, and poisoning. The most common primary assessments from places of recreation or sport were traumatic injury, syncope/fainting, altered level of consciousness, respiratory distress, and abdominal pain. The most common primary assessments from health care facilities were behavioral/psychiatric disorder, traumatic injury, abdominal pain, respiratory distress, and syncope/fainting. When examining the mechanism of injury for trauma-related primary assessments, falls were the most common mechanism at all 3 locations, followed by being struck by an object. Of the 1335 serious-incident calls (11% of the total EMS activations meeting inclusion criteria), 61.2% were from public buildings, 14.1% from places of recreation or sport, and 24.7% from health care facilities. Our identification of common EMS dispatch complaints, mechanisms of injury, and primary assessments can be used in the education of staff and preparation of facilities for medical emergencies and injuries where children spend time.

Simultaneous cerebrovascular and cardiovascular responses during presyncope

NASA Technical Reports Server (NTRS)

Bondar, R. L.; Kassam, M. S.; Stein, F.; Dunphy, P. T.; Fortney, S.; Riedesel, M. L.

1995-01-01

BACKGROUND AND PURPOSE: Presyncope, characterized by symptoms and signs indicative of imminent syncope, can be aborted in many situations before loss of consciousness occurs. The plasticity of cerebral autoregulation in healthy humans and its behavior during this syncopal prodrome are unclear, although systemic hemodynamic instability has been suggested as a key factor in the precipitation of syncope. Using lower body negative pressure (LBNP) to simulate central hypovolemia, we previously observed falling mean flow velocities (MFVs) with maintained mean arterial blood pressure (MABP). These findings, and recent reports suggesting increased vascular tone within the cerebral vasculature at presyncope, cannot be explained by the classic static cerebral autoregulation curve; neither can they be totally explained by a recent suggestion of a rightward shift in this curve. METHODS: Four male and five female healthy volunteers were exposed to presyncopal LBNP to evaluate their cerebrovascular and cardiovascular responses by use of continuous acquisition of MFV from the right middle cerebral artery with transcranial Doppler sonography, MABP (Finapres), and heart rate (ECG). RESULTS: At presyncope, MFV dropped on average by 27.3 +/- 14% of its baseline value (P < .05), while MABP remained at 2.0 +/- 27% above its baseline level. Estimated cerebrovascular resistance increased during LBNP. The percentage change from baseline to presyncope in MFV and MABP revealed consistent decreases in MFV before MABP. CONCLUSIONS: Increased estimated cerebrovascular resistance, falling MFV, and constant MABP are evidence of an increase in cerebral vascular tone with falling flow, suggesting a downward shift in the cerebral autoregulation curve. Cerebral vessels may have a differential sensitivity to sympathetic drive or more than one type of sympathetic innervation. Future work to induce dynamic changes in MABP during LBNP may help in assessing the plasticity of the cerebral autoregulation mechanism.

Feasibility of a pilot intervention to reduce pain and syncope during adolescent vaccination.

PubMed

Henninger, Michelle L; Kuntz, Jennifer L; Firemark, Alison J; Varga, Alexandra M; Bok, Karin; Naleway, Allison L

2018-05-24

Vaccines recommended for adolescents are considered safe and effective, however administration may occasionally result in acute pain at the injection site or syncope (fainting). These adverse effects pose a risk to patient safety and are potential barriers to adherence to future vaccinations. We assessed a novel intervention designed to help prevent acute pain and syncope associated with adolescent vaccinations. We conducted a 3-month pilot study to assess the feasibility and acceptability of a vaccination comfort menu within two Kaiser Permanente Northwest pediatric clinics. The menu offered a variety of comfort items (e.g., cold packs, squeeze balls) that children could select prior to their vaccination. We surveyed parents of recently vaccinated adolescents and interviewed providers to assess the implementation and effectiveness of the intervention. Response rate for the parent survey was 33% (378/1136). Only 20% of the parents reported that their provider offered the comfort menu during the vaccination visit. Approximately 50% of the adolescents who were offered the menu selected a comfort item and most of these participants reported that the item was very (35%) or somewhat (38%) helpful in improving their vaccination experience. Per provider interviews, common barriers to implementing the intervention included lack of time and convenience, and the brevity of the pilot period. The comfort menu may improve the vaccination experience of youth and increase the likelihood of adherence with future vaccinations. However, only 20% of the parents reported that their provider offered the menu during the vaccination visit. Additional research is needed to determine the feasibility of implementing this intervention on a larger scale, as well as assessing whether the intervention has a significant impact on reducing adverse events. Copyright © 2018. Published by Elsevier Ltd.

Predicting Vasovagal Syncope from Heart Rate and Blood Pressure: A Prospective Study in 140 Subjects.

PubMed

Virag, Nathalie; Erickson, Mark; Taraborrelli, Patricia; Vetter, Rolf; Lim, Phang Boon; Sutton, Richard

2018-04-28

We developed a vasovagal syncope (VVS) prediction algorithm for use during head-up tilt with simultaneous analysis of heart rate (HR) and systolic blood pressure (SBP). We previously tested this algorithm retrospectively in 1155 subjects, showing sensitivity 95%, specificity 93% and median prediction time of 59s. This study was prospective, single center, on 140 subjects to evaluate this VVS prediction algorithm and assess if retrospective results were reproduced and clinically relevant. Primary endpoint was VVS prediction: sensitivity and specificity >80%. In subjects, referred for 60° head-up tilt (Italian protocol), non-invasive HR and SBP were supplied to the VVS prediction algorithm: simultaneous analysis of RR intervals, SBP trends and their variability represented by low-frequency power generated cumulative risk which was compared with a predetermined VVS risk threshold. When cumulative risk exceeded threshold, an alert was generated. Prediction time was duration between first alert and syncope. Of 140 subjects enrolled, data was usable for 134. Of 83 tilt+ve (61.9%), 81 VVS events were correctly predicted and of 51 tilt-ve subjects (38.1%), 45 were correctly identified as negative by the algorithm. Resulting algorithm performance was sensitivity 97.6%, specificity 88.2%, meeting primary endpoint. Mean VVS prediction time was 2min 26s±3min16s with median 1min 25s. Using only HR and HR variability (without SBP) the mean prediction time reduced to 1min34s±1min45s with median 1min13s. The VVS prediction algorithm, is clinically-relevant tool and could offer applications including providing a patient alarm, shortening tilt-test time, or triggering pacing intervention in implantable devices. Copyright © 2018. Published by Elsevier Inc.

Donor anxiety, needle pain, and syncopal reactions combine to determine retention: a path analysis of two-year donor return data.

PubMed

France, Christopher R; France, Janis L; Wissel, Mary Ellen; Ditto, Blaine; Dickert, Tara; Himawan, Lina K

2013-09-01

Efforts to expand the donor pool by recruiting younger donors have resulted in higher numbers of initial donations, but retention of young donors continues to be challenging. Path analysis was used to examine the simultaneous relationships among syncopal reactions, donation anxiety, needle pain, donor satisfaction, and donation intention in predicting repeat donation. Participants included 421 first- and second-time donors recruited for a study comparing the effects of predonation water loading with and without the use of applied muscle tension during donation (52% female, 60.8% first-time donor, mean age 20.3 years). For this longitudinal follow-up study, donor database records were accessed 2 years after the index donation to assess repeat donation. Results of a series of path analyses demonstrated the influential role of donor anxiety in shaping donor retention (final model χ(2) = 35.75, root mean square error of approximation 0.03, comparative fit index 0.98, weighted root mean square residual 0.74). First, anxiety exerted a direct negative influence on donation intention, the proximal and sole direct predictor of repeat donation. Second, anxiety increased the likelihood of donor-reported needle pain, adversely affecting donation satisfaction and, subsequently, donation intention. Finally, anxiety was associated with donor ratings of syncopal reactions through its impact on needle pain, which also contributed to decreased donation intention. These results provide novel evidence that donation anxiety plays a central role in shaping future donation behavior. Individual differences in anxiety must be considered when developing and testing strategies to enhance blood donor retention. © 2013 American Association of Blood Banks.

Balloon atrial septostomy in pulmonary arterial hypertension: effect on survival and associated outcomes.

PubMed

Chiu, Joanne S; Zuckerman, Warren A; Turner, Mariel E; Richmond, Marc E; Kerstein, Diane; Krishnan, Usha; Torres, Alejandro; Vincent, Julie A; Rosenzweig, Erika B

2015-03-01

Pulmonary arterial hypertension (PAH) is a progressive disease that, without early identification and treatment, may lead to right heart failure, multi-organ dysfunction and early death. In severe PAH, in addition to maximal medical therapy, balloon atrial septostomy (BAS) may be used for palliation and as a bridge to lung transplantation. We present our contemporary institutional experience utilizing BAS in adult and pediatric patients with severe PAH. We performed a retrospective analysis of 46 BASs performed in 32 patients with PAH from 2002 to 2013. Data obtained included vital status, functional class, medications, hemodynamic measurements from right heart catheterizations and biomarkers. Lung transplantation-free and repeat-BAS-free survival was analyzed. Median age at BAS was 23 (range 1 to 56) years. The most common indications were symptomatic right heart failure (21 of 46 patients) and pre-syncope/syncope (19 of 46 patients); 69% of patients were WHO Functional Class III or IV pre-BAS. There were no procedural complications or deaths. There were no significant differences in biomarkers or hemodynamic findings between pre-BAS and 1 year or latest follow-up. Seven patients were successfully bridged to lung transplantation. Lung transplantation-free and repeat-BAS-free survival at 30 days, 1 year and 5 years was 87%, 61% and 32%, respectively. In our experienced center, BAS was shown to be safe in patients with severe PAH on maximal medical management, with no procedural deaths or complications. BAS was safely used as a bridge to lung transplantation or to alleviate right heart failure symptoms and/or syncope. Other potential benefits for end-organ function and overall survival remain to be determined. Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

Teaching as Jazz

ERIC Educational Resources Information Center

Tomlinson, Carol Ann; Germundson, Amy

2007-01-01

Tomlinson and Germundson compare teaching well to playing jazz well. Excellent teaching involves a blend of techniques and theory; expressiveness; syncopation; call and response, and, frequently, improvisation. Weaving in analogies to jazz, the authors delineate four elements of such teaching: curriculum that helps students connect to big ideas,…

[Variability of heart rhythm in dynamic study of the psychovegetative relationship in neurogenic syncope].

PubMed

Musaeva, Z A; Khaspekova, N B; Veĭn, A M

2001-01-01

Physiological changes accompanying syncopes of neural origin (SNO) in patients with psychovegetative syndrome are still insufficiently studied. The data concerning the role of the autonomic nervous system are discrepant. Heart rate variability was analyzed in 68 patients with SNO in a supine position and during the active 20-min orthostatic test taking into account the heart rate components of very low frequency (VLF, an index of cerebral sympathetic activity) and high frequency (HF, a marker of vagal modulation). Steady growth of the VLF and progressive decrease in the LF within 15-20 min of the orthostasis were observed in all the patients (n = 33), who fainted after this period. The predominance of the VLF in the heart rate power spectra was correlated with a high level of anxiety. It is suggested that this fact indicates the stable cerebral sympathetic activation resulting in a baroreceptor dysfunction, i.e., a failure of vasomotor regulation in patients with SNO.

Hyperventilation, cerebral perfusion, and syncope.

PubMed

Immink, R V; Pott, F C; Secher, N H; van Lieshout, J J

2014-04-01

This review summarizes evidence in humans for an association between hyperventilation (HV)-induced hypocapnia and a reduction in cerebral perfusion leading to syncope defined as transient loss of consciousness (TLOC). The cerebral vasculature is sensitive to changes in both the arterial carbon dioxide (PaCO2) and oxygen (PaO2) partial pressures so that hypercapnia/hypoxia increases and hypocapnia/hyperoxia reduces global cerebral blood flow. Cerebral hypoperfusion and TLOC have been associated with hypocapnia related to HV. Notwithstanding pronounced cerebrovascular effects of PaCO2 the contribution of a low PaCO2 to the early postural reduction in middle cerebral artery blood velocity is transient. HV together with postural stress does not reduce cerebral perfusion to such an extent that TLOC develops. However when HV is combined with cardiovascular stressors like cold immersion or reduced cardiac output brain perfusion becomes jeopardized. Whether, in patients with cardiovascular disease and/or defect, cerebral blood flow cerebral control HV-induced hypocapnia elicits cerebral hypoperfusion, leading to TLOC, remains to be established.

A Bermuda Triangle of Science

ERIC Educational Resources Information Center

Winkelsas, John

2006-01-01

The Bermuda Triangle is famous for the unexplained disappearances of ships and aircraft, and for strange meteorological phenomena that allegedly have occurred within its boundaries. This article presents an activity wherein students are asked to create their own geographical triangles to research, but instead of focusing on the unexplainable,…

Now & Then: Roger Whitmore, Police Officer.

ERIC Educational Resources Information Center

Barnes, Sue; Michalowicz, Karen Dee

1995-01-01

Discusses police officers' use of mathematics when reconstructing an accident scene; and the history of algebra, including al-Khwarizmi's works on the theory of equations, the Rhind Papyrus, a Chinese and an Indian manuscript on systems of linear and quadratic equations, and Diophantus'"syncopated algebra." (10 references) (EK)

A retrospective analysis of 538 sinonasal fungus ball cases treated at a single tertiary medical center in Korea (1996-2015).

PubMed

Yoon, Young Hoon; Xu, Jun; Park, Soo Kyoung; Heo, Jae Hyung; Kim, Yong Min; Rha, Ki-Sang

2017-11-01

Sinonasal fungus ball (FB) is a type of noninvasive fungal rhinosinusitis affecting immunocompetent hosts. FB, previously considered rare, has been reported with increasing frequency. We reviewed our experience of 538 cases over the past 20 years. We retrospectively examined clinical records including clinical presentations, radiological findings, management, and outcomes of FB patients who have undergone surgery for treatment. The number of FB patients who underwent endoscopic sinus surgery (ESS) was calculated annually. Causal relationships between structural variations and FB were also investigated. The number of FB patients who underwent sinus surgery has increased. The mean age was 58.3 years, and the gender ratio was approximately 2 (female): 1 (male). While the most common presenting symptoms of maxillary sinus FB patients were nasal symptoms, such as postnasal drip and nasal obstruction, sphenoid sinus FB patients presented with headache mostly. On computed tomography (CT) scans, the most common finding was intralesional hyperdensity (77.3%). There was no significant correlation between the presence of FB and structural variations (nasal septal deviation, concha bullosa, Haller cell). Median follow-up period of the patients was 11 months. Recurrence or residual disease occurred in only 6 (1.1%) cases. The number of FB patients who underwent surgery has increased steadily over the past 20 years. FB should be considered in patients with unilateral nasal symptoms and unexplained headaches. A preoperative CT scan is an essential tool in making diagnosis easier and faster. Endoscopic surgery is the treatment of choice, with a low morbidity and recurrence rate. © 2017 ARS-AAOA, LLC.

Reduced expressions of connexin 43 and VEGF in the first-trimester tissues from women with recurrent pregnancy loss.

PubMed

He, Xiaoping; Chen, Qinfang

2016-08-17

Approximately 45-50 % of the recurrent pregnancy loss (RPL) remain(s) unexplained that challenges its clinical management. Formation and development of placenta as well as angiogenesis are critical for successful pregnancy. Vascular endothelial growth factor (VEGF) and connexin 43 (Cx43) play important roles in angiogenesis and placenta development and aberration of these have been linked to RPL. We aimed to investigate whether the expressions of VEGF and Cx43 were altered in the first-trimester tissues (chorionic villi and decidua) collected from women with RPL compared to those from healthy early pregnant women. First-trimester chorionic villi and decidua were collected from pregnant women diagnosed RPL who ended up with surgical intervention (n = 28) in comparison to those collected from women requesting surgical termination of their unwanted normal first-trimester pregnancies (n = 28). These two groups of women were matched in age and gestational weeks. Tissues were analyzed for the protein and messenger ribonucleic acid (mRNA) expressions of Cx43 and VEGF by immunohistochemistry, western blot, and quantitative reverse transcription polymerase chain reaction (qRT-PCR). The expressions of both Cx43 and VEGF at the level of mRNA and protein in the villi and decidua from women with RPL were significantly decreased compared with those from women with normal early pregnancy. Reduction of Cx43 and VEGF expressed in the first-trimester tissues might indicate their important roles involved in RPL and thus holds the potential to develop pharmaceutical therapies for treatment of RPL.

Novel evidences of atypical manifestations in cryopyrin-associated periodic syndromes.

PubMed

Bujan-Rivas, Segundo; Basagaña, Maria; Sena, Francisca; Méndez, Maria; Dordal, Maria Teresa; Gonzalez-Roca, Eva; Ruiz-Ortiz, Estibaliz; Mensa-Vilaró, Anna; Plaza, Susana; Modesto, Consuelo; Ordi-Ros, Josep; Yagüe, Jordi; Martínez-Valle, Ferrán; Aróstegui, Juan Ignacio

2017-01-01

Cryopyrin-associated periodic syndromes (CAPS) usually start during infancy as an urticarial-like rash and a marked acute phase response, with additional manifestations appearing during its evolution. The aim of this study was to expand the clinical diversity of CAPS by the description of novel atypical features. Clinical data were collected from patients' medical charts. Sanger sequencing analyzed NLRP3. Response to anti-IL-1 blockade was evaluated by clinical assessments and by measurements of laboratory parameters. Seventeen patients from two families (A and B), carrying the p.Ala439Thr and p.Arg260Trp NLRP3 mutations respectively, were enrolled. The disease was unexpectedly atypical in all members of Family A, with a 16-year-old asymptomatic carrier, and onset in adulthood associated with absence of skin lesions in four affected members. Surprisingly, one patient from each family suffered from severe haemorrhagic cystitis due to AA amyloidosis in the urinary bladder. Members of Family B displayed a classical phenotype, with two patients suffering from olfactive disorders. Our evidence suggests that CAPS may occasionally be presented as a late-onset, recurrent inflammatory disease without urticarial-like rash. In some patients, AA amyloidosis in strange locations like urinary bladder may complicate the clinical course. The response to IL-1 blockade in these atypical CAPS was similar to that described in classical forms. Consequently, we suggest that CAPS should be included in the differential diagnosis of adult patients with unexplained, recurrent inflammatory diseases, and once confirmed, the early initiation of anti-IL-1 blockade will probably prevent the development of life-threatening complications.

Rs4265085 in GPER1 gene increases the risk for unexplained recurrent spontaneous abortion in Dai and Bai ethnic groups in China.

PubMed

Tang, Liang; Zheng, Shui; Wang, Yan; Li, Fang; Bao, Meihua; Zeng, Jie; Xiang, Ju; Luo, Huaiqing; Li, Jianming

2017-04-01

Oestrogen receptors are implicated in the pathogenesis of recurrent spontaneous abortion (RSA). Non-genomic oestrogen responses can be mediated by GPER. The prevalence of polymorphisms in GPER1 gene in RSA was assessed in 747 Chinese women from Yunnan province (171 Bai, 258 Chinese Han, 234 Dai, 33 Achang and 51 Jingpo patients). Snapshot technology was used for genotyping the polymorphisms of the GPER1 gene. The rs4265085G was significantly increased in the Dai and Bai groups versus controls (Dai: P < 0.0001, P adj < 0.0001, OR 95% CI 2.34 [1.79 to 3.05]; Bai: P = 0.0004, P adj = 0.0012, OR 95% CI 1.71 [1.27 to 2.31]); recessive model of rs4265085 in the Dai (P = 0.003, P adj = 0.009, OR 95% CI 2.71 [1.38 to 5.30]); Bai (P < 0.0001, P adj < 0.0001, OR 95% CI 3.37 [1.93 to 5.91]). Haplotype frequencies containing rs10269151G-rs4265085G-rs11544331C were separately significantly different in Dai and Bai ethnic groups (Dai: P = 0.0002, P adj = 0.001, OR 95% CI = 2.12 [1.43 to 3.17]; Bai: P = 0.005, P adj = 0.025, OR 95% CI = 1.82 [1.18 to 2.78]) compared with controls. The intron variant rs4265085 may confer risk for RSA in Dai and Bai ethnic groups. Copyright © 2017 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

A single-center audit of the indications and clinical impact of prolonged ambulatory small intestinal manometry.

PubMed

Ang, D; Pannemans, J; Vanuytsel, T; Tack, J

2018-05-01

Small bowel manometry is a diagnostic test available only in a few specialized referral centers. Its exact place in the management of refractory symptoms is controversial. The records of all patients who underwent 24-hour ambulatory duodenojejunal manometry over a 6-year period were retrospectively reviewed. We studied the clinical indications for small bowel manometry, and reviewed the impact of manometric findings on the clinical outcome. One hundred and forty-six studies were performed in 137 patients (46M, 91F) with a mean age of 44.9 ± 15.7 years. Mean follow-up duration was 15.1 ± 22.6 months. Appropriate endoscopic, radiological and gastric scintigraphy studies were performed in all patients prior to small bowel manometry. Criteria for abnormal motor activity were based on Bharucha's classification. The indications for small bowel manometry were chronic abdominal pain (n = 43), slow-transit constipation (n = 17), refractory gastroparesis (n = 16), chronic diarrhea (n = 7), recurrent episodes of subocclusion (n = 16), postsurgical evaluation (n = 36), suspicion of gut involvement in systemic disease (n = 9), and unexplained nausea (n = 2). The most common finding was a normal 24-hour ambulatory small bowel manometry (n = 113). Thirty-three studies yielded abnormal findings which included extrinsic neuropathy (n = 6), intrinsic neuropathy (n = 18), intestinal myopathy (n = 2), and subocclusion (n = 7). Ambulatory small bowel manometry excluded a generalized motility disorder in 77% and had a significant impact on the subsequent clinical course in 23%. Ambulatory small bowel manometry is a useful and safe diagnostic tool to complement traditional investigative modalities in patients with severe unexplained abdominal symptoms. © 2018 John Wiley & Sons Ltd.

Improved heat tolerance in air drives the recurrent evolution of air-breathing.

PubMed

Giomi, Folco; Fusi, Marco; Barausse, Alberto; Mostert, Bruce; Pörtner, Hans-Otto; Cannicci, Stefano

2014-05-07

The transition to air-breathing by formerly aquatic species has occurred repeatedly and independently in fish, crabs and other animal phyla, but the proximate drivers of this key innovation remain a long-standing puzzle in evolutionary biology. Most studies attribute the onset of air-breathing to the repeated occurrence of aquatic hypoxia; however, this hypothesis leaves the current geographical distribution of the 300 genera of air-breathing crabs unexplained. Here, we show that their occurrence is mainly related to high environmental temperatures in the tropics. We also demonstrate in an amphibious crab that the reduced cost of oxygen supply in air extends aerobic performance to higher temperatures and thus widens the animal's thermal niche. These findings suggest that high water temperature as a driver consistently explains the numerous times air-breathing has evolved. The data also indicate a central role for oxygen- and capacity-limited thermal tolerance not only in shaping sensitivity to current climate change but also in underpinning the climate-dependent evolution of animals, in this case the evolution of air-breathing.

When one disease is not enough: succinyl-CoA: 3-oxoacid coenzyme A transferase (SCOT) deficiency due to a novel mutation in OXCT1 in an infant with known phenylketonuria.

PubMed

Schwade, Jan-Niclas; Endmann, Matthias; Hofmann, Thomas; Rust, Stephan; Sass, Jörn Oliver; Rutsch, Frank

2017-10-26

A 9-month-old Turkish girl was admitted several times within 3 months to the hospital in reduced general condition and with extreme tachypnea. The patient had been diagnosed with phenylketonuria (PKU) in newborn screening and has been treated with a low phenylalanine diet and amino acid supplements. Each time an unexplained pronounced metabolic acidosis was noted, and the child was treated with sodium-bicarbonate and glucose-electrolyte infusions. The acidosis with only slightly abnormal glucose, normal lactate levels and pronounced ketonuria suggested a defect in ketone body utilization. Succinyl-CoA: 3-oxoacid CoA transferase (SCOT) enzyme activity was low in patient's fibroblasts. Mutation analysis of the corresponding OXCT1 gene revealed that the patient was a homozygous carrier of the mutation c.1523T>C (p.V508A). We conclude that SCOT deficiency should be considered in the differential diagnosis in patients with recurrent metabolic acidotic episodes, even if they are already known to have a metabolic disease unrelated to this.

Improved heat tolerance in air drives the recurrent evolution of air-breathing

PubMed Central

Giomi, Folco; Fusi, Marco; Barausse, Alberto; Mostert, Bruce; Pörtner, Hans-Otto; Cannicci, Stefano

2014-01-01

The transition to air-breathing by formerly aquatic species has occurred repeatedly and independently in fish, crabs and other animal phyla, but the proximate drivers of this key innovation remain a long-standing puzzle in evolutionary biology. Most studies attribute the onset of air-breathing to the repeated occurrence of aquatic hypoxia; however, this hypothesis leaves the current geographical distribution of the 300 genera of air-breathing crabs unexplained. Here, we show that their occurrence is mainly related to high environmental temperatures in the tropics. We also demonstrate in an amphibious crab that the reduced cost of oxygen supply in air extends aerobic performance to higher temperatures and thus widens the animal's thermal niche. These findings suggest that high water temperature as a driver consistently explains the numerous times air-breathing has evolved. The data also indicate a central role for oxygen- and capacity-limited thermal tolerance not only in shaping sensitivity to current climate change but also in underpinning the climate-dependent evolution of animals, in this case the evolution of air-breathing. PMID:24619438